Provider Demographics
NPI:1689908147
Name:WOOD, TALIA R (RD)
Entity Type:Individual
Prefix:MS
First Name:TALIA
Middle Name:R
Last Name:WOOD
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:P.O. BOX 1946
Mailing Address - Street 2:1090 GOAT SPRINGS ROAD
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-1946
Mailing Address - Country:US
Mailing Address - Phone:575-758-4224
Mailing Address - Fax:575-751-5210
Practice Address - Street 1:1090 GOAT SPRINGS ROAD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-1946
Practice Address - Country:US
Practice Address - Phone:575-758-4224
Practice Address - Fax:575-751-5210
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-0623133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM8HR149OtherMEDICARE PTAN
NMK3543Medicaid
NM84600381Medicaid
NMHSZ189OtherMEDICARE PART B
NM8HR149OtherMEDICARE PTAN