Healthcare Provider Details

I. General information

NPI: 1669650446
Provider Name (Legal Business Name): TRACI J STAMATAKOS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACI JEANETTE. JERKINS RD

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 08/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 PIEDMONT AVE
CINCINNATI OH
45219-4231
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTALING
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-8523
  • Fax: 513-475-7327
Mailing address:
  • Phone: 513-245-3104
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLP.10285-A
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD.6187
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: