Provider Demographics
NPI:1326739673
Name:RICKMAN, TIFFANY (MPH, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:RICKMAN
Suffix:
Gender:F
Credentials:MPH, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3922 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-8948
Mailing Address - Country:US
Mailing Address - Phone:217-565-3833
Mailing Address - Fax:
Practice Address - Street 1:3922 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-8948
Practice Address - Country:US
Practice Address - Phone:217-565-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.008555133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered