Provider Demographics
NPI:1235536293
Name:ANDERSON, TINA MARIE (RD,LDN, MPH, CDE)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RD,LDN, MPH, CDE
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:BONA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD,LDN,MPH,CDE
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-3120
Mailing Address - Fax:
Practice Address - Street 1:501 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2618
Practice Address - Country:US
Practice Address - Phone:239-424-3120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND11044133NN1002X, 133V00000X, 133N00000X
IL164.000203133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121494700Medicaid