Provider Demographics
NPI:1104172261
Name:TIMMONS, TRACEY ELIZABETH (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:ELIZABETH
Last Name:TIMMONS
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 NELSON RD APT 616
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-0801
Mailing Address - Country:US
Mailing Address - Phone:337-479-0473
Mailing Address - Fax:
Practice Address - Street 1:3236 KIRKMAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8640
Practice Address - Country:US
Practice Address - Phone:337-480-2632
Practice Address - Fax:337-475-8613
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1847133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered