Provider Demographics
NPI:1437542230
Name:BISSELL, TEGAN (RD, LDN, CDCES)
Entity Type:Individual
Prefix:
First Name:TEGAN
Middle Name:
Last Name:BISSELL
Suffix:
Gender:F
Credentials:RD, LDN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 COCONUT AVE E
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-1328
Mailing Address - Country:US
Mailing Address - Phone:802-376-8964
Mailing Address - Fax:
Practice Address - Street 1:3496 NW FEDERAL HWY
Practice Address - Street 2:SUITE F
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4441
Practice Address - Country:US
Practice Address - Phone:772-223-4916
Practice Address - Fax:772-223-2887
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2023-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND6894133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered