Provider Demographics
NPI:1326312257
Name:MUSSELMAN, TINA MARIE (MA, RD, LDN, CCN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:MUSSELMAN
Suffix:
Gender:F
Credentials:MA, RD, LDN, CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13830 S ARAPAHO TRL
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-9626
Mailing Address - Country:US
Mailing Address - Phone:708-846-5816
Mailing Address - Fax:
Practice Address - Street 1:20201 CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1010
Practice Address - Country:US
Practice Address - Phone:708-747-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004149133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered