Provider Demographics
NPI:1376178723
Name:ANDERSON, TAMARA J (RDN)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W1206 STATE HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:WI
Mailing Address - Zip Code:54614-9112
Mailing Address - Country:US
Mailing Address - Phone:608-780-8943
Mailing Address - Fax:
Practice Address - Street 1:500 E VETERANS ST
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-3105
Practice Address - Country:US
Practice Address - Phone:608-372-3971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered