Provider Demographics
NPI:1568056687
Name:CAMPBELL, TRACIE (RDN)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:CAMPBELL
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 1:384 SE COMBS FLAT RD
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-2562
Mailing Address - Country:US
Mailing Address - Phone:541-460-4088
Mailing Address - Fax:
Practice Address - Street 1:384 SE COMBS FLAT RD
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-2562
Practice Address - Country:US
Practice Address - Phone:541-460-4088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR527628133V00000X
ORLD-D-10200368133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered