Basic Information
| Provider Information | |||||||||
| NPI: | 1376178723 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | W1206 STATE HIGHWAY 16 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546149112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087808943 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 E VETERANS ST | ||||||||
| Address2: | |||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546603105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083723971 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2020 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.