Provider Demographics
NPI:1568781482
Name:WEESE, TAMARA A (RD)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:A
Last Name:WEESE
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 1:405 CLOWE CT
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3409
Mailing Address - Country:US
Mailing Address - Phone:619-890-2411
Mailing Address - Fax:
Practice Address - Street 1:1617 N CALIFORNIA ST STE 2G
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6117
Practice Address - Country:US
Practice Address - Phone:209-461-5268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-18
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA963050133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered