Provider Demographics
NPI:1073341335
Name:SAUPAN, TRACY (MS, RDN, LDN)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:SAUPAN
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1027 SHANGRILA ST BLDG 1867
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:91-1027 SHANGRILA ST BLDG 1867
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2101
Practice Address - Country:US
Practice Address - Phone:808-674-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI428-LD133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered