Provider Demographics
NPI:1962804344
Name:DAVIS, TRACY ROSE (RD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ROSE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RD
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 1404
Mailing Address - Street 2:
Mailing Address - City:PORT ARANSAS
Mailing Address - State:TX
Mailing Address - Zip Code:78373-1404
Mailing Address - Country:US
Mailing Address - Phone:361-443-4084
Mailing Address - Fax:
Practice Address - Street 1:627 N PALIMINO DR
Practice Address - Street 2:
Practice Address - City:PORT ARANSAS
Practice Address - State:TX
Practice Address - Zip Code:78373-6000
Practice Address - Country:US
Practice Address - Phone:361-443-4084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81222133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered