Provider Demographics
NPI:1154448199
Name:TRACY, NICOLE L (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:L
Last Name:TRACY
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 CHURCHILL DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-2081
Mailing Address - Country:US
Mailing Address - Phone:630-776-1766
Mailing Address - Fax:630-548-5274
Practice Address - Street 1:1004 CHURCHILL DR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-2081
Practice Address - Country:US
Practice Address - Phone:630-776-1766
Practice Address - Fax:630-548-5274
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.002997133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric