Healthcare Provider Details

I. General information

NPI: 1811210511
Provider Name (Legal Business Name): TAMMY PETROSSIAN RD, CSP, CNSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2010
Last Update Date: 03/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 SAN JUAN AVE
EXETER CA
93221-1312
US

IV. Provider business mailing address

1631 E FOREST OAKS DR
FRESNO CA
93730-4535
US

V. Phone/Fax

Practice location:
  • Phone: 559-592-7360
  • Fax: 559-592-5629
Mailing address:
  • Phone: 559-434-6332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number816014
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number816014
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: