Provider Demographics
NPI:1992789341
Name:EASTRIDGE, TRACY LYNN (RD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:EASTRIDGE
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4525 CAMERON VALLEY PKWY
Practice Address - Street 2:STE 4100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4369
Practice Address - Country:US
Practice Address - Phone:704-302-9462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002783133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3400032SMedicaid
NC3697OtherWELLPATH
NC371708500OtherDEPARTMENT OF LABOR
NC5040770OtherUNITED HEALTHCARE
NC0590625010OtherCIGNA
NC680HOSOtherPARTNERS MEDICARE HMO
NC00207OtherBLUE CROSS
NC3400032Medicaid
NC0067840OtherAETNA
NC312280OtherFEDERAL BLACK LUNG
NC3400032SMedicaid