Healthcare Provider Details

I. General information

NPI: 1902714199
Provider Name (Legal Business Name): TRACI PETTY SCOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 RICHLAND MEDICAL PARK DR STE 230
COLUMBIA SC
29203-6859
US

IV. Provider business mailing address

524 WOODLAND DR
KERSHAW SC
29067-1703
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-7990
  • Fax:
Mailing address:
  • Phone: 803-804-9430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number32498
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: