Provider Demographics
NPI:1548726417
Name:FENNEMORE, TRACY ELLEN (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ELLEN
Last Name:FENNEMORE
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:TRAY
Other - Middle Name:HARPER
Other - Last Name:FENNEMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED DIETITIAN
Mailing Address - Street 1:399 SCARLET CIR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-5658
Mailing Address - Country:US
Mailing Address - Phone:302-264-9790
Mailing Address - Fax:
Practice Address - Street 1:399 SCARLET CIR
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-5658
Practice Address - Country:US
Practice Address - Phone:302-264-9790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEDN0000272133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered