Provider Demographics
NPI:1851417273
Name:CICIRALE, TRACEY L (RD,LDN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:CICIRALE
Suffix:
Gender:F
Credentials:RD,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16609 BLACKFOOT DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-1501
Mailing Address - Country:US
Mailing Address - Phone:815-588-4016
Mailing Address - Fax:815-588-4016
Practice Address - Street 1:16609 BLACKFOOT DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-1501
Practice Address - Country:US
Practice Address - Phone:815-588-4016
Practice Address - Fax:815-588-4016
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric