Healthcare Provider Details

I. General information

NPI: 1528821725
Provider Name (Legal Business Name): TRACY C RICHARDSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4378 OLEANDER DR STE 6
MYRTLE BEACH SC
29577-5981
US

IV. Provider business mailing address

4378 OLEANDER DR SUITE #6
MYRTLE BEACH SC
29577-5981
US

V. Phone/Fax

Practice location:
  • Phone: 854-894-4633
  • Fax:
Mailing address:
  • Phone: 854-894-4633
  • Fax: 854-894-4005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number28323
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28323
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: