Provider Demographics
NPI:1306961602
Name:PFAFFENBERGER, TRACY JEANNINE (RD, CD)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:JEANNINE
Last Name:PFAFFENBERGER
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 S HOME ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-3134
Mailing Address - Country:US
Mailing Address - Phone:574-256-9568
Mailing Address - Fax:574-256-0817
Practice Address - Street 1:129 S HOME ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-3134
Practice Address - Country:US
Practice Address - Phone:574-256-9568
Practice Address - Fax:574-256-0817
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000231A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered