Healthcare Provider Details

I. General information

NPI: 1083993562
Provider Name (Legal Business Name): TRACEY SOULIA MS, RD, CDN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2011
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W BAY PLZ
PLATTSBURGH NY
12901-1785
US

IV. Provider business mailing address

1211 JERSEY SWAMP RD
MORRISONVILLE NY
12962-3920
US

V. Phone/Fax

Practice location:
  • Phone: 518-569-2505
  • Fax: 888-357-3499
Mailing address:
  • Phone: 518-569-2505
  • Fax: 888-357-3499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number007197-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: