Healthcare Provider Details

I. General information

NPI: 1891867099
Provider Name (Legal Business Name): TRACY STIVERS MS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 MANCHESTER SQUARE
MANCHESTER KY
40962-9998
US

IV. Provider business mailing address

PO BOX 555
MANCHESTER KY
40962
US

V. Phone/Fax

Practice location:
  • Phone: 606-598-7673
  • Fax: 606-598-7942
Mailing address:
  • Phone: 606-598-3836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0370
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: