Provider Demographics
NPI:1295288926
Name:DILLON, TRACEY (RD, LRD)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:DILLON
Suffix:
Gender:F
Credentials:RD, LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 GOLD DR S
Mailing Address - Street 2:STE 101
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6413
Mailing Address - Country:US
Mailing Address - Phone:701-280-2033
Mailing Address - Fax:
Practice Address - Street 1:3001 SANFORD PKWY
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2700
Practice Address - Country:US
Practice Address - Phone:218-683-2709
Practice Address - Fax:218-683-4518
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3720133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered