Basic Information
| Provider Information | |||||||||
| NPI: | 1073892295 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALVERSON | ||||||||
| FirstName: | TYRA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 S L ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984053720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534033131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 311 S L ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984053720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534033131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2011 | ||||||||
| LastUpdateDate: | 08/04/2011 | ||||||||
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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 | 133N00000X | N | Dietary & Nutritional Service Providers | Nutritionist | 133NN1002X | N | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | 133VN1004X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric |
No ID Information.