Basic Information
| Provider Information | |||||||||
| NPI: | 1497701601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWEARINGEN | ||||||||
| FirstName: | TRACIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LARSON | ||||||||
| OtherFirstName: | TRACIE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11850 BLACKFOOT STREET NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637122100 | ||||||||
| FaxNumber: | 7637122190 | ||||||||
| Practice Location | |||||||||
| Address1: | 3960 COON RAPIDS BLVD NW | ||||||||
| Address2: | SUITE 311 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637122100 | ||||||||
| FaxNumber: | 7637122190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/25/2016 | ||||||||
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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 | 875741 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.