Provider Demographics
NPI:1710490164
Name:GUAJARDO, TINA (MA, RD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:GUAJARDO
Suffix:
Gender:F
Credentials:MA, RD
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:KELLENBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, RD
Mailing Address - Street 1:363 FREMONT ST STE 109
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3395
Mailing Address - Country:US
Mailing Address - Phone:269-245-8318
Mailing Address - Fax:
Practice Address - Street 1:363 FREMONT ST STE 109
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3395
Practice Address - Country:US
Practice Address - Phone:269-245-8318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered