Provider Demographics
NPI:1669594024
Name:RIDDLE, TRACY LYNNE (DO)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYNNE
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNNE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3988 W ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9200
Mailing Address - Country:US
Mailing Address - Phone:231-935-0860
Mailing Address - Fax:231-935-0930
Practice Address - Street 1:3988 W ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-9200
Practice Address - Country:US
Practice Address - Phone:231-935-0860
Practice Address - Fax:231-935-0930
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI016737208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation