Provider Demographics
NPI:1275414823
Name:A WALTERS, TRACIA A
Entity type:Individual
Prefix:
First Name:TRACIA
Middle Name:A
Last Name:A WALTERS
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 1:3327 WAGGONER LN
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-5220
Mailing Address - Country:US
Mailing Address - Phone:678-353-7916
Mailing Address - Fax:
Practice Address - Street 1:3327 WAGGONER LN
Practice Address - Street 2:
Practice Address - City:REX
Practice Address - State:GA
Practice Address - Zip Code:30273-5220
Practice Address - Country:US
Practice Address - Phone:678-353-7916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA25064627311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home