Provider Demographics
NPI:1659018554
Name:HENDERSON, TRACIE (RDN)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:HENDERSON
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 1:2201 GRASSY KNOLL LN
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-1716
Mailing Address - Country:US
Mailing Address - Phone:804-385-9231
Mailing Address - Fax:
Practice Address - Street 1:1500 N 28TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-5332
Practice Address - Country:US
Practice Address - Phone:804-764-7885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered