Provider Demographics
NPI:1497127252
Name:SWARTZENTRUBER, TIFFANY AUTUMN (RD, CSO, CD)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:AUTUMN
Last Name:SWARTZENTRUBER
Suffix:
Gender:F
Credentials:RD, CSO, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HIGH PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4810
Mailing Address - Country:US
Mailing Address - Phone:574-364-2455
Mailing Address - Fax:574-364-2544
Practice Address - Street 1:200 HIGH PARK AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4810
Practice Address - Country:US
Practice Address - Phone:574-364-2455
Practice Address - Fax:574-364-2544
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001894A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered