Provider Demographics
NPI:1639393556
Name:ANDERSON, TRACY R (MS, RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:MS
Other - First Name:TRACY
Other - Middle Name:R
Other - Last Name:GANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LDN
Mailing Address - Street 1:323 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-4221
Mailing Address - Country:US
Mailing Address - Phone:309-648-9507
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0002
Practice Address - Country:US
Practice Address - Phone:309-672-4240
Practice Address - Fax:309-672-4953
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered