Provider Demographics
NPI:1619743978
Name:MIRZA, TENLEY SIMMONS (CNS LDN)
Entity Type:Individual
Prefix:
First Name:TENLEY
Middle Name:SIMMONS
Last Name:MIRZA
Suffix:
Gender:F
Credentials:CNS LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:NORWELL
Mailing Address - State:MA
Mailing Address - Zip Code:02061-1426
Mailing Address - Country:US
Mailing Address - Phone:781-659-1234
Mailing Address - Fax:
Practice Address - Street 1:21 PARKER ST
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1426
Practice Address - Country:US
Practice Address - Phone:781-659-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALDN3796133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist