Provider Demographics
NPI:1861646911
Name:TRACY, VIRGINIA MARGUERITE (NC)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:MARGUERITE
Last Name:TRACY
Suffix:
Gender:F
Credentials:NC
Other - Prefix:
Other - First Name:GINGER
Other - Middle Name:MARGUERITE
Other - Last Name:TRACY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NC
Mailing Address - Street 1:526 WOOD DUCK DR
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-2132
Mailing Address - Country:US
Mailing Address - Phone:707-718-4718
Mailing Address - Fax:
Practice Address - Street 1:526 WOOD DUCK DR
Practice Address - Street 2:
Practice Address - City:SUISUN CITY
Practice Address - State:CA
Practice Address - Zip Code:94585-2132
Practice Address - Country:US
Practice Address - Phone:707-718-4718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANC912005133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist