Provider Demographics
NPI:1124094321
Name:BOOTH, TRACY MARIE (MA, RDN)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:MARIE
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MA, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6640
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49516-6640
Mailing Address - Country:US
Mailing Address - Phone:616-929-4026
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 6640
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49516-6640
Practice Address - Country:US
Practice Address - Phone:616-929-4026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI723477133V00000X, 133NN1002X, 133VN1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1301XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Oncology