Provider Demographics
NPI:1740605641
Name:GLENN, TIFFANY (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CASA DEL RANCHO RD
Mailing Address - Street 2:
Mailing Address - City:LORENA
Mailing Address - State:TX
Mailing Address - Zip Code:76655-3179
Mailing Address - Country:US
Mailing Address - Phone:254-716-0332
Mailing Address - Fax:
Practice Address - Street 1:500 CASA DEL RANCHO RD
Practice Address - Street 2:
Practice Address - City:LORENA
Practice Address - State:TX
Practice Address - Zip Code:76655-3179
Practice Address - Country:US
Practice Address - Phone:254-716-0332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT03912133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered