Basic Information
| Provider Information | |||||||||
| NPI: | 1356430763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEARCE | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | |||||||||
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| Credential: | L.R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 15TH AVE W | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588013821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017747492 | ||||||||
| FaxNumber: | 7017747479 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 15TH AVE W | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588013821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017747492 | ||||||||
| FaxNumber: | 7017747479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 406 | ND | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 342 | MT | N | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 0000298578 | 01 | MT | BLUE CROSS BLUE SHIELD | OTHER | 25590 | 01 | ND | BLUE CROSS BLUE SHIELD | OTHER | 21320 | 01 | ND | BLUE CROSS BLUE SHIELD | OTHER | 52930 | 05 | ND | MEDICAID | 13078 | 01 | ND | BLUE CROSS OF ND | OTHER |