Provider Demographics
NPI:1376665810
Name:EISENHOWER, TRACI LEE (RD,LD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LEE
Last Name:EISENHOWER
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13801 CRESTON PL
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-2157
Mailing Address - Country:US
Mailing Address - Phone:561-523-8208
Mailing Address - Fax:
Practice Address - Street 1:13801 CRESTON PL
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-2157
Practice Address - Country:US
Practice Address - Phone:561-523-8208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND2856133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered