Healthcare Provider Details

I. General information

NPI: 1710113410
Provider Name (Legal Business Name): TRACY MASTANDREA RD,LD/N
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9180 FOREST HILL BLVD
WELLINGTON FL
33411-6564
US

IV. Provider business mailing address

9423 COVENTRY LAKE CT
WEST PALM BEACH FL
33411-6602
US

V. Phone/Fax

Practice location:
  • Phone: 561-358-2408
  • Fax:
Mailing address:
  • Phone: 561-358-2408
  • Fax: 561-333-5374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND3715
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberND3715
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND3715
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: