Provider Demographics
NPI:1508179920
Name:BLAKEMAN, TRACY M (MS, RD)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:M
Last Name:BLAKEMAN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 VALLEY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49333-9157
Mailing Address - Country:US
Mailing Address - Phone:616-633-3549
Mailing Address - Fax:
Practice Address - Street 1:2727 VALLEY RIDGE DR
Practice Address - Street 2:
Practice Address - City:MIDDLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:49333-9157
Practice Address - Country:US
Practice Address - Phone:616-633-3549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI721639133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI133V00000XMedicaid