Provider Demographics
NPI:1992938757
Name:JOHNSON, TRACY LYNN (CFTS)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CFTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8504 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-3397
Mailing Address - Country:US
Mailing Address - Phone:910-599-7077
Mailing Address - Fax:910-397-2867
Practice Address - Street 1:2309 S 17TH ST STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-8006
Practice Address - Country:US
Practice Address - Phone:910-392-5806
Practice Address - Fax:910-397-2867
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCFTS0582335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCFTS0582OtherABC