Provider Demographics
NPI:1487288411
Name:DENNIS, TRACY JANE (RDN)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:JANE
Last Name:DENNIS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:JANE
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 N MAPLE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2094
Mailing Address - Country:US
Mailing Address - Phone:217-787-8870
Mailing Address - Fax:
Practice Address - Street 1:500 N MAPLE ST STE 200
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2094
Practice Address - Country:US
Practice Address - Phone:217-787-8870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-28
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164007635133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered