Provider Demographics
NPI:1467770370
Name:TRACY, RYAN PATRICK (MS, RD, LD)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:PATRICK
Last Name:TRACY
Suffix:
Gender:M
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 YELLOW PINE DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-9233
Mailing Address - Country:US
Mailing Address - Phone:228-861-7740
Mailing Address - Fax:
Practice Address - Street 1:200 YELLOW PINE DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-9233
Practice Address - Country:US
Practice Address - Phone:228-861-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1208133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered