Provider Demographics
NPI:1336890011
Name:BURKETT, TRACY (LC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BURKETT
Suffix:
Gender:F
Credentials:LC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 CLUB VIEW DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-8419
Mailing Address - Country:US
Mailing Address - Phone:828-777-2696
Mailing Address - Fax:
Practice Address - Street 1:5050 CLUB VIEW DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-8419
Practice Address - Country:US
Practice Address - Phone:828-777-2696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL-303365174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN