Provider Demographics
NPI:1285918342
Name:BRASSARD, TIFFANY MOORE (RD)
Entity type:Individual
Prefix:MISS
First Name:TIFFANY
Middle Name:MOORE
Last Name:BRASSARD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 JABARRAH AVE
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR JOHNSON A F B
Mailing Address - State:NC
Mailing Address - Zip Code:27531-2310
Mailing Address - Country:US
Mailing Address - Phone:919-722-1822
Mailing Address - Fax:919-722-1952
Practice Address - Street 1:1050 JABARRAH AVE
Practice Address - Street 2:
Practice Address - City:SEYMOUR JOHNSON A F B
Practice Address - State:NC
Practice Address - Zip Code:27531-2310
Practice Address - Country:US
Practice Address - Phone:919-722-1822
Practice Address - Fax:919-722-1952
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003702133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered