Provider Demographics
NPI:1710391669
Name:GREEN, TRACY JO (RD)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:JO
Last Name:GREEN
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 1:705 EBONY ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5643
Mailing Address - Country:US
Mailing Address - Phone:208-221-9085
Mailing Address - Fax:
Practice Address - Street 1:705 EBONY ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5643
Practice Address - Country:US
Practice Address - Phone:208-221-9085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-748133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered