Provider Demographics
NPI:1356096887
Name:O'NEILL, TRACEY (CNS, LDN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:O'NEILL
Suffix:
Gender:F
Credentials:CNS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CANAL RD
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4300
Mailing Address - Country:US
Mailing Address - Phone:904-535-6901
Mailing Address - Fax:
Practice Address - Street 1:500 CANAL RD
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4300
Practice Address - Country:US
Practice Address - Phone:904-535-6901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND11248133V00000X
171400000X
MDDX5575133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No171400000XOther Service ProvidersHealth & Wellness Coach