Provider Demographics
NPI:1649588344
Name:FITZGERALD, THERESA BLUM (RD,LD)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:BLUM
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 IRVIN DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-9775
Mailing Address - Country:US
Mailing Address - Phone:432-684-0860
Mailing Address - Fax:
Practice Address - Street 1:4214 ANDREWS HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-4822
Practice Address - Country:US
Practice Address - Phone:432-522-3045
Practice Address - Fax:432-522-3096
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDTO2558133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered