Provider Demographics
NPI:1821718040
Name:EDWARDS, TRACIE (PTA)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-3840
Mailing Address - Country:US
Mailing Address - Phone:252-523-0082
Mailing Address - Fax:
Practice Address - Street 1:312 WARREN AVE
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-3840
Practice Address - Country:US
Practice Address - Phone:252-523-0082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3698225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant