Provider Demographics
NPI:1477924678
Name:STAM, TRACY STOVER (RDN)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:STOVER
Last Name:STAM
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:MRS
Other - First Name:TRACY
Other - Middle Name:S
Other - Last Name:STAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDN
Mailing Address - Street 1:11120 TAMARRON PL
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80138-3116
Mailing Address - Country:US
Mailing Address - Phone:303-717-4391
Mailing Address - Fax:
Practice Address - Street 1:11120 TAMARRON PL
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-3116
Practice Address - Country:US
Practice Address - Phone:303-717-4391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
819174133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric