Provider Demographics
NPI:1083993562
Name:SOULIA, TRACEY (MS, RD, CDN, CDE)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:
Last Name:SOULIA
Suffix:
Gender:F
Credentials:MS, RD, CDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 JERSEY SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:MORRISONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12962-3920
Mailing Address - Country:US
Mailing Address - Phone:518-569-2505
Mailing Address - Fax:888-357-3499
Practice Address - Street 1:110 W BAY PLZ
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1785
Practice Address - Country:US
Practice Address - Phone:518-569-2505
Practice Address - Fax:888-357-3499
Is Sole Proprietor?:No
Enumeration Date:2011-08-15
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007197-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered