Provider Demographics
NPI:1154787877
Name:SHREVE, TRACY THOMAS (FNP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:THOMAS
Last Name:SHREVE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:ANN
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1530 DRAYTON ROAD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307
Practice Address - Country:US
Practice Address - Phone:864-560-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19945363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4503Medicaid
SCSCA1635019OtherMEDICARE PIN