=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275908048
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANNA TRACY PHIFER RD, LDN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2015
-----------------------------------------------------
Last Update Date | 02/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 E MAIN ST
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61832-5100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-554-5395
-----------------------------------------------------
Fax | 217-554-4828
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 721A CLINIC DR
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-877-5030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133VN1301X
-----------------------------------------------------
Taxonomy Name | Oncology Nutrition Registered Dietitian
-----------------------------------------------------
License Number | DT85370
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------