Provider Demographics
NPI:1285848465
Name:WOOD, TINA R (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:R
Last Name:WOOD
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:MS
Other - First Name:TINA
Other - Middle Name:R
Other - Last Name:SCHWARZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD
Mailing Address - Street 1:909 AMETHYST LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6854
Mailing Address - Country:US
Mailing Address - Phone:573-634-7873
Mailing Address - Fax:
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5192
Practice Address - Fax:573-632-5879
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001023574133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO00401234Medicare ID - Type UnspecifiedMEDICARE MNT CPIN