Provider Demographics
NPI:1881201408
Name:FISHER, TYLA MARIE (RDN)
Entity type:Individual
Prefix:
First Name:TYLA
Middle Name:MARIE
Last Name:FISHER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 BLACK HILLS ST
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-6573
Mailing Address - Country:US
Mailing Address - Phone:303-898-3257
Mailing Address - Fax:
Practice Address - Street 1:3724 JEFFERSON ST STE 104
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6204
Practice Address - Country:US
Practice Address - Phone:303-898-3257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY339133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered