Provider Demographics
NPI:1962286641
Name:FAMBROUGH, TRACY M (SA-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:FAMBROUGH
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:M
Other - Last Name:HAMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 936535
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 GLEN ECHO RD STE 111
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215-2857
Practice Address - Country:US
Practice Address - Phone:615-657-4805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant