Provider Demographics
NPI:1053089946
Name:MCKELVEY, TRACY (RD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:MCKELVEY
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 1:18735 FAIRFAX LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-7018
Mailing Address - Country:US
Mailing Address - Phone:714-915-1539
Mailing Address - Fax:
Practice Address - Street 1:19722 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-2404
Practice Address - Country:US
Practice Address - Phone:949-824-8770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA819517133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered