Provider Demographics
NPI:1578105714
Name:HARGRAVE-KLEIN, TANYA JANE (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:JANE
Last Name:HARGRAVE-KLEIN
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3347 FOXLEY DR
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-1110
Mailing Address - Country:US
Mailing Address - Phone:515-460-0169
Mailing Address - Fax:
Practice Address - Street 1:3210 SE CORPORATE WOODS DR
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-7405
Practice Address - Country:US
Practice Address - Phone:833-444-4036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
LA3060133V00000X
DCD1100001093133V00000X
DEDN-0000777133V00000X
MN4212133V00000X
IA00980133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered