Provider Demographics
NPI:1871675157
Name:TRACY, AMANDA D (ND)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:D
Last Name:TRACY
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401-A WATERMAN BLVD
Mailing Address - Street 2:STE 4 #296
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-1800
Mailing Address - Country:US
Mailing Address - Phone:781-726-2878
Mailing Address - Fax:
Practice Address - Street 1:118 CHERRY VALLEY CT
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-7514
Practice Address - Country:US
Practice Address - Phone:707-759-5029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0990000188175F00000X
CAND1178175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath