Provider Demographics
NPI:1487079877
Name:KELECAVA, TRACY (NP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:KELECAVA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:SUITE 300 REGIONAL HEALTHPLUS
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-2168
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:8311 WARREN H ABERNATHY HWY
Practice Address - Street 2:SUITE 300 REGIONAL HEALTHPLUS
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-1249
Practice Address - Country:US
Practice Address - Phone:864-560-9696
Practice Address - Fax:864-562-5230
Is Sole Proprietor?:No
Enumeration Date:2014-02-22
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18527363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2845Medicaid
SCNP2845Medicaid