Provider Demographics
NPI:1245091859
Name:SMITH, TRACY Y
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:Y
Last Name:SMITH
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 1:224 TIMBERLEAF DR
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334-9297
Mailing Address - Country:US
Mailing Address - Phone:864-631-7768
Mailing Address - Fax:
Practice Address - Street 1:224 TIMBERLEAF DR
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:SC
Practice Address - Zip Code:29334-9297
Practice Address - Country:US
Practice Address - Phone:864-631-7768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC004112580172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver