Provider Demographics
NPI:1265643019
Name:WIEDEMAN, TAMMY ALVAREZ (RD, LD,N)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:ALVAREZ
Last Name:WIEDEMAN
Suffix:
Gender:F
Credentials:RD, LD,N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 FEATHERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-6913
Mailing Address - Country:US
Mailing Address - Phone:904-247-5588
Mailing Address - Fax:
Practice Address - Street 1:3100 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 220
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2758
Practice Address - Country:US
Practice Address - Phone:904-724-2043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4613133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered