Provider Demographics
NPI:1104589175
Name:POWELL, TRACIE (RN)
Entity type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 MILLER TOWN RD
Mailing Address - Street 2:
Mailing Address - City:PAULINE
Mailing Address - State:SC
Mailing Address - Zip Code:29374-2322
Mailing Address - Country:US
Mailing Address - Phone:864-641-5760
Mailing Address - Fax:
Practice Address - Street 1:124 MILLER TOWN RD
Practice Address - Street 2:
Practice Address - City:PAULINE
Practice Address - State:SC
Practice Address - Zip Code:29374-2322
Practice Address - Country:US
Practice Address - Phone:864-641-5760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC205571163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health