Provider Demographics
NPI:1134979412
Name:FORTUNATI, TARYN MARCIA (RD)
Entity type:Individual
Prefix:
First Name:TARYN
Middle Name:MARCIA
Last Name:FORTUNATI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7712 KNOLLBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-3625
Mailing Address - Country:US
Mailing Address - Phone:925-548-9109
Mailing Address - Fax:
Practice Address - Street 1:7712 KNOLLBROOK DR
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-3625
Practice Address - Country:US
Practice Address - Phone:925-548-9109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86099838133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered