Provider Demographics
NPI:1124674866
Name:COGDELL, TRACIE
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:COGDELL
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 1:1904 WATERCREST DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-8031
Mailing Address - Country:US
Mailing Address - Phone:404-720-5359
Mailing Address - Fax:
Practice Address - Street 1:217 ARROWHEAD BLVD BLDG SUITE2A
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1169
Practice Address - Country:US
Practice Address - Phone:404-720-5359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)