Provider Demographics
NPI:1033117569
Name:ROESCH, TRACY M
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:M
Last Name:ROESCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 S MONROE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:WI
Mailing Address - Zip Code:53813-2099
Mailing Address - Country:US
Mailing Address - Phone:608-723-2143
Mailing Address - Fax:608-723-7595
Practice Address - Street 1:507 S MONROE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:WI
Practice Address - Zip Code:53813-2054
Practice Address - Country:US
Practice Address - Phone:608-723-3262
Practice Address - Fax:605-723-6325
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered