Provider Demographics
NPI:1821258781
Name:NEWELL, TRACY LYNN (RD LD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:NEWELL
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1309
Mailing Address - Street 2:MAIL STOP 21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-1309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8170 33RD AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-4516
Practice Address - Country:US
Practice Address - Phone:952-883-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1720133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered