Provider Demographics
NPI:1104451483
Name:LEWIS, TRACEY MICHELLE (APRN, NP-C)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:MICHELLE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 N MYRTLE POINT BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-2224
Mailing Address - Country:US
Mailing Address - Phone:843-366-3060
Mailing Address - Fax:
Practice Address - Street 1:2021 N MYRTLE POINT BLVD STE 102
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-2224
Practice Address - Country:US
Practice Address - Phone:843-366-3060
Practice Address - Fax:843-366-3069
Is Sole Proprietor?:No
Enumeration Date:2020-03-07
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24580363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily