Provider Demographics
NPI:1740906478
Name:TAN, VIVIAN (RD)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:TAN
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 1:1755 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-1141
Mailing Address - Country:US
Mailing Address - Phone:917-588-6517
Mailing Address - Fax:
Practice Address - Street 1:165 VANDERBILT AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2521
Practice Address - Country:US
Practice Address - Phone:718-616-0993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01062601133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered