Provider Demographics
NPI:1811210511
Name:PETROSSIAN, TAMMY (RD, CSP, CNSD)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:PETROSSIAN
Suffix:
Gender:F
Credentials:RD, CSP, CNSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 E FOREST OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93730-4535
Mailing Address - Country:US
Mailing Address - Phone:559-434-6332
Mailing Address - Fax:
Practice Address - Street 1:1014 SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:CA
Practice Address - Zip Code:93221-1312
Practice Address - Country:US
Practice Address - Phone:559-592-7360
Practice Address - Fax:559-592-5629
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA816014133V00000X, 133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered