Provider Demographics
NPI:1104045871
Name:RAY, TRACI ANN (MS RD)
Entity Type:Individual
Prefix:MISS
First Name:TRACI
Middle Name:ANN
Last Name:RAY
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11388 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-8437
Mailing Address - Country:US
Mailing Address - Phone:812-894-2205
Mailing Address - Fax:812-894-2205
Practice Address - Street 1:2200 N SECTION ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-7523
Practice Address - Country:US
Practice Address - Phone:812-268-4311
Practice Address - Fax:812-268-2648
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN864188133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered