Provider Demographics
NPI:1376670018
Name:GOLDSMITH, TAMMY LYN (RD)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:LYN
Last Name:GOLDSMITH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 LAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1656
Mailing Address - Country:US
Mailing Address - Phone:616-774-0853
Mailing Address - Fax:616-774-0328
Practice Address - Street 1:1225 LAKE DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1656
Practice Address - Country:US
Practice Address - Phone:616-774-0853
Practice Address - Fax:616-774-0328
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI818826133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered