Healthcare Provider Details

I. General information

NPI: 1851417273
Provider Name (Legal Business Name): TRACEY L. CICIRALE RD,LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 08/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16609 BLACKFOOT DR
LOCKPORT IL
60441-1501
US

IV. Provider business mailing address

16609 BLACKFOOT DR
LOCKPORT IL
60441-1501
US

V. Phone/Fax

Practice location:
  • Phone: 815-588-4016
  • Fax: 815-588-4016
Mailing address:
  • Phone: 815-588-4016
  • Fax: 815-588-4016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: