Provider Demographics
NPI:1386687648
Name:NISLY, TAMARA JEAN (REGISTERED DIETICIAN)
Entity Type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:JEAN
Last Name:NISLY
Suffix:
Gender:F
Credentials:REGISTERED DIETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-3700
Mailing Address - Country:US
Mailing Address - Phone:928-771-3122
Mailing Address - Fax:928-771-3369
Practice Address - Street 1:10 S 6TH ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4236
Practice Address - Country:US
Practice Address - Phone:928-639-8130
Practice Address - Fax:928-639-8179
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ956889133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ095604Medicaid