Basic Information
| Provider Information | |||||||||
| NPI: | 1033694096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRIESON | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | CLARICE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | M.S., R.D.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1628 | ||||||||
| Address2: | |||||||||
| City: | LAKE ISABELLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932401628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603792681 | ||||||||
| FaxNumber: | 7603792321 | ||||||||
| Practice Location | |||||||||
| Address1: | 6412 LAUREL AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE ISABELLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932409529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603792681 | ||||||||
| FaxNumber: | 7603794795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2018 | ||||||||
| LastUpdateDate: | 09/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86065532 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.