Provider Demographics
NPI:1568026268
Name:VIA, TRACIE (RDN)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:VIA
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 BLUFF CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30656-8640
Mailing Address - Country:US
Mailing Address - Phone:404-394-7038
Mailing Address - Fax:
Practice Address - Street 1:1421 BLUFF CREEK TRL
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30656-8640
Practice Address - Country:US
Practice Address - Phone:404-394-7038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-28
Last Update Date:2019-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001209133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered