Provider Demographics
NPI:1366322075
Name:SMITH, TRACY L (RD)
Entity type:Individual
Prefix:MR
First Name:TRACY
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 S DR MLK JR BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-6062
Mailing Address - Country:US
Mailing Address - Phone:386-295-1071
Mailing Address - Fax:
Practice Address - Street 1:917 S DR MLK JR BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-6062
Practice Address - Country:US
Practice Address - Phone:386-295-1071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5954133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty