Basic Information
| Provider Information | |||||||||
| NPI: | 1104045871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAY | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | MS RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11388 LAKE RD | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478028437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128942205 | ||||||||
| FaxNumber: | 8128942205 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 N SECTION ST | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478827523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122684311 | ||||||||
| FaxNumber: | 8122682648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 864188 | IN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.