Provider Demographics
NPI:1588024483
Name:MOORE, TRACY (RD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4105
Mailing Address - Country:US
Mailing Address - Phone:866-907-1068
Mailing Address - Fax:425-917-9141
Practice Address - Street 1:3220 PROVIDENCE DR
Practice Address - Street 2:SUITE E3-030
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4679
Practice Address - Country:US
Practice Address - Phone:907-212-7982
Practice Address - Fax:907-212-7981
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10161588133V00000X
AK119517133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered