Provider Demographics
NPI:1427650621
Name:GONZALES, TIFFANY (RD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GONZALES
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 1:4555 VISCANO AVE
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-3023
Mailing Address - Country:US
Mailing Address - Phone:661-477-1971
Mailing Address - Fax:
Practice Address - Street 1:4555 VISCANO AVE
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-3023
Practice Address - Country:US
Practice Address - Phone:661-477-1971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered