Provider Demographics
NPI:1710113410
Name:MASTANDREA, TRACY (RD,LD/N)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:MASTANDREA
Suffix:
Gender:F
Credentials:RD,LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9423 COVENTRY LAKE CT
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6602
Mailing Address - Country:US
Mailing Address - Phone:561-358-2408
Mailing Address - Fax:561-333-5374
Practice Address - Street 1:9180 FOREST HILL BLVD
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33411-6564
Practice Address - Country:US
Practice Address - Phone:561-358-2408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND3715133N00000X, 133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education