Healthcare Provider Details

I. General information

NPI: 1114853397
Provider Name (Legal Business Name): TRACIE AMMONS MISTRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 HIGHWAY 17 N STE 106
NORTH MYRTLE BEACH SC
29582-8107
US

IV. Provider business mailing address

7601 N OCEAN BLVD APT 4B
MYRTLE BEACH SC
29572-4252
US

V. Phone/Fax

Practice location:
  • Phone: 843-742-1430
  • Fax: 843-663-0623
Mailing address:
  • Phone: 843-742-1430
  • Fax: 843-663-0623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1616
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: