Provider Demographics
NPI:1316414709
Name:MARTIN, TRACEY DIANE (MS, CN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:DIANE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS, CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24846 NE 1ST PL
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074-3429
Mailing Address - Country:US
Mailing Address - Phone:206-940-8134
Mailing Address - Fax:
Practice Address - Street 1:24846 NE 1ST PL
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98074-3429
Practice Address - Country:US
Practice Address - Phone:206-940-8134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60891688133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist