Provider Demographics
NPI:1164810016
Name:BOLIN, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:BOLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14218 W BLUEGRASS CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-8065
Mailing Address - Country:US
Mailing Address - Phone:316-312-6388
Mailing Address - Fax:
Practice Address - Street 1:2020 N TYLER RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-4905
Practice Address - Country:US
Practice Address - Phone:316-312-6388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1966133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered