Provider Demographics
NPI:1366068744
Name:KMIECIK, TRACEY (MPH, RD)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:KMIECIK
Suffix:
Gender:F
Credentials:MPH, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5450 LEARY AVE NW APT 643
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4081
Mailing Address - Country:US
Mailing Address - Phone:206-614-0010
Mailing Address - Fax:206-614-0015
Practice Address - Street 1:5450 LEARY AVE NW APT 643
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4081
Practice Address - Country:US
Practice Address - Phone:714-943-5530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60912554133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered