Provider Demographics
NPI:1487971339
Name:SHAFFER, TRACEY LYNN (RD)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:RD
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 830242
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0242
Mailing Address - Country:US
Mailing Address - Phone:615-425-4200
Mailing Address - Fax:
Practice Address - Street 1:1014 VINE ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202-1141
Practice Address - Country:US
Practice Address - Phone:855-699-6937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-30
Last Update Date:2025-05-05
Deactivation Date:2013-05-13
Deactivation Code:
Reactivation Date:2013-06-14
Provider Licenses
StateLicense IDTaxonomies
OR10220695133V00000X
MDDX5577133V00000X
WADI61281597133V00000X
TXDT87459133V00000X
OH09740133V00000X
OK2710133V00000X
WI6059-29133V00000X
MO2007003698133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered