Basic Information
| Provider Information | |||||||||
| NPI: | 1073279261 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMARAL | ||||||||
| FirstName: | TANISHA | ||||||||
| MiddleName: | SOUSA | ||||||||
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| Credential: | RD, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 ELLENFIELD ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014445640 | ||||||||
| FaxNumber: | 4014445462 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 CHAPMAN ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014447152 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2021 | ||||||||
| LastUpdateDate: | 11/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LDN01134 | RI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.