Provider Demographics
NPI:1811540545
Name:TOVAR-DIAZ, BREANNA MACKENZIE (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:MACKENZIE
Last Name:TOVAR-DIAZ
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:
Other - Last Name:FOUNTAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LDN
Mailing Address - Street 1:20930 DUPONT BLVD UNIT 202
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19947-1724
Mailing Address - Country:US
Mailing Address - Phone:302-202-3438
Mailing Address - Fax:
Practice Address - Street 1:20930 DUPONT BLVD UNIT 202
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-1724
Practice Address - Country:US
Practice Address - Phone:302-202-3438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEDN-0000765133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered