Provider Demographics
NPI:1801398193
Name:HOLT, TIFFANY LEE (RD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LEE
Last Name:HOLT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:LEE
Other - Last Name:CRAIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:858-334-4643
Practice Address - Fax:858-334-4641
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86028973133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered