Provider Demographics
NPI:1588357792
Name:ELLEGARD, TIFFANY (MS, RDN)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:ELLEGARD
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 SEVILLE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3850
Mailing Address - Country:US
Mailing Address - Phone:480-527-8999
Mailing Address - Fax:
Practice Address - Street 1:6124 E BROWN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4959
Practice Address - Country:US
Practice Address - Phone:480-527-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered