Provider Demographics
NPI:1992298426
Name:GUNNEMANN, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GUNNEMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21342 HILLSIDE CT
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6598
Mailing Address - Country:US
Mailing Address - Phone:949-702-2153
Mailing Address - Fax:
Practice Address - Street 1:21342 HILLSIDE CT
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-6598
Practice Address - Country:US
Practice Address - Phone:949-702-2153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-09
Last Update Date:2018-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86069391133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered