Provider Demographics
NPI:1033486972
Name:GRANT, TRACEY A (RD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:A
Last Name:GRANT
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 1:1046 E WESLEYAN DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-3819
Mailing Address - Country:US
Mailing Address - Phone:817-905-6467
Mailing Address - Fax:
Practice Address - Street 1:1046 E WESLEYAN DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-3819
Practice Address - Country:US
Practice Address - Phone:817-905-6467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1050263133V00000X
WADI60260239133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8905950Medicare PIN