Provider Demographics
NPI:1710119508
Name:GIMENEZ, TAMMIE JENKINS (MHS,RD,LD)
Entity Type:Individual
Prefix:MRS
First Name:TAMMIE
Middle Name:JENKINS
Last Name:GIMENEZ
Suffix:
Gender:F
Credentials:MHS,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:PO BOX 434
Mailing Address - Street 2:
Mailing Address - City:LEAD HILL
Mailing Address - State:AR
Mailing Address - Zip Code:72644
Mailing Address - Country:US
Mailing Address - Phone:870-414-4047
Mailing Address - Fax:
Practice Address - Street 1:620 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2911
Practice Address - Country:US
Practice Address - Phone:870-414-4047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR489133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W901Medicare PIN