Provider Demographics
NPI:1902251556
Name:BLACKMON-PAYLOR, TRACY
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:BLACKMON-PAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 N REILLY RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-2574
Mailing Address - Country:US
Mailing Address - Phone:910-494-4968
Mailing Address - Fax:
Practice Address - Street 1:732 DALMORE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-1133
Practice Address - Country:US
Practice Address - Phone:910-494-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-02
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC1000521744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management