Provider Demographics
NPI:1588178743
Name:POLEGA, TRACY LEE (RDN, RD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:POLEGA
Suffix:
Gender:F
Credentials:RDN, RD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LEE
Other - Last Name:OTTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:53405 WOLF DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-2647
Mailing Address - Country:US
Mailing Address - Phone:989-798-8269
Mailing Address - Fax:
Practice Address - Street 1:53405 WOLF DR
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-2647
Practice Address - Country:US
Practice Address - Phone:989-798-8269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86081294133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered