Healthcare Provider Details

I. General information

NPI: 1659133593
Provider Name (Legal Business Name): TRACEY ANN REEVES LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2024
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 WHITE INGRAM PKWY
DALLAS GA
30132-0969
US

IV. Provider business mailing address

5694 SUNBURST DR
POWDER SPRINGS GA
30127-5491
US

V. Phone/Fax

Practice location:
  • Phone: 770-615-0951
  • Fax:
Mailing address:
  • Phone: 770-371-2616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN080501
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: