Provider Demographics
NPI:1003423682
Name:KUSSAT, TENNY (RD)
Entity Type:Individual
Prefix:
First Name:TENNY
Middle Name:
Last Name:KUSSAT
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 1:655 PARK CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-3094
Mailing Address - Country:US
Mailing Address - Phone:619-596-5575
Mailing Address - Fax:
Practice Address - Street 1:655 PARK CENTER DR
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3094
Practice Address - Country:US
Practice Address - Phone:619-596-5575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
809647133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered