Provider Demographics
NPI:1962442368
Name:CARDELLI, TRACY (RD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:CARDELLI
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 1:887 CONGRESS ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3100
Mailing Address - Country:US
Mailing Address - Phone:207-662-5522
Mailing Address - Fax:207-662-5527
Practice Address - Street 1:39 WALLACE AVE
Practice Address - Street 2:
Practice Address - City:SO PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6143
Practice Address - Country:US
Practice Address - Phone:207-761-0650
Practice Address - Fax:207-761-8198
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MED1438133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMT068101Medicare PIN