Provider Demographics
NPI:1104489673
Name:TRACY, MOLLIE MCLEOD (RDN)
Entity type:Individual
Prefix:MS
First Name:MOLLIE
Middle Name:MCLEOD
Last Name:TRACY
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:MS
Other - First Name:MOLLIE
Other - Middle Name:CATHERINE
Other - Last Name:MCLEOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:2057 DREAM CATCHER PLZ
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-2729
Mailing Address - Country:US
Mailing Address - Phone:315-829-8700
Mailing Address - Fax:
Practice Address - Street 1:2057 DREAM CATCHER PLZ
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2729
Practice Address - Country:US
Practice Address - Phone:315-829-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1046166133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01705682Medicaid