Healthcare Provider Details

I. General information

NPI: 1396572491
Provider Name (Legal Business Name): MADELINE TIMM RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2024
Last Update Date: 07/22/2026
Certification Date: 09/14/2024
Deactivation Date: 02/04/2025
Reactivation Date: 07/22/2026

III. Provider practice location address

211 CARL ST
SAN FRANCISCO CA
94117-3804
US

IV. Provider business mailing address

211 CARL ST
SAN FRANCISCO CA
94117-3804
US

V. Phone/Fax

Practice location:
  • Phone: 612-412-8064
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: