Provider Demographics
NPI:1508693516
Name:TANKERSLEY, HEIDI
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:TANKERSLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 HORACE ST
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-3640
Mailing Address - Country:US
Mailing Address - Phone:734-334-0908
Mailing Address - Fax:
Practice Address - Street 1:2485 HORACE ST
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48324-3640
Practice Address - Country:US
Practice Address - Phone:734-334-0908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86069091133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered