Provider Demographics
NPI:1922534635
Name:JUDY, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:JUDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:PO BOX 162
Mailing Address - City:REEVESVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29471-0162
Mailing Address - Country:US
Mailing Address - Phone:843-636-1001
Mailing Address - Fax:
Practice Address - Street 1:8423 OLD STATE RD # A
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:SC
Practice Address - Zip Code:29059-8100
Practice Address - Country:US
Practice Address - Phone:803-759-3012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC53782163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health