Healthcare Provider Details

I. General information

NPI: 1487971339
Provider Name (Legal Business Name): TRACEY LYNN SHAFFER R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2010
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date: 05/13/2013
Reactivation Date: 06/14/2013

III. Provider practice location address

1014 VINE ST
CINCINNATI OH
45202-1141
US

IV. Provider business mailing address

PO BOX 830242
PHILADELPHIA PA
19182-0242
US

V. Phone/Fax

Practice location:
  • Phone: 855-699-6937
  • Fax:
Mailing address:
  • Phone: 615-425-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number10220695
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX5577
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI61281597
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT87459
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number09740
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2710
License Number StateOK
# 7
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number6059-29
License Number StateWI
# 8
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2007003698
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: