Basic Information
| Provider Information | |||||||||
| NPI: | 1962442368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARDELLI | ||||||||
| FirstName: | TRACY | ||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 887 CONGRESS ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076625522 | ||||||||
| FaxNumber: | 2076625527 | ||||||||
| Practice Location | |||||||||
| Address1: | 39 WALLACE AVE | ||||||||
| Address2: | |||||||||
| City: | SO PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041066143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077610650 | ||||||||
| FaxNumber: | 2077618198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 06/03/2013 | ||||||||
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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 | D1438 | ME | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.