Provider Demographics
NPI:1609445907
Name:WALLA, TIFFANY (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WALLA
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 BROTHERS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-5474
Mailing Address - Country:US
Mailing Address - Phone:936-337-3223
Mailing Address - Fax:
Practice Address - Street 1:1217 AVENUE M STE 113
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-4650
Practice Address - Country:US
Practice Address - Phone:936-337-2981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85084133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered