Provider Demographics
NPI:1962958587
Name:LONG, TRACEY (MPH, RDN)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MPH, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6824 W 72ND TER
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66204-1920
Mailing Address - Country:US
Mailing Address - Phone:303-588-9701
Mailing Address - Fax:
Practice Address - Street 1:6824 W 72ND TER
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66204-1920
Practice Address - Country:US
Practice Address - Phone:303-588-9701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS86068129133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered