Provider Demographics
NPI:1295107084
Name:RATHBONE, TRACEY
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:RATHBONE
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 1:961 PAINTERS GAP RD
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORDTON
Mailing Address - State:NC
Mailing Address - Zip Code:28139-9519
Mailing Address - Country:US
Mailing Address - Phone:828-223-6972
Mailing Address - Fax:
Practice Address - Street 1:380 US 221 HWY N
Practice Address - Street 2:
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139-7616
Practice Address - Country:US
Practice Address - Phone:828-223-6972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC LMBT 6127172V00000X
NC6127171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171W00000XOther Service ProvidersContractor