Healthcare Provider Details

I. General information

NPI: 1235536293
Provider Name (Legal Business Name): TINA MARIE ANDERSON RD,LDN, MPH, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TINA MARIE BONA RD,LDN,MPH,CDE

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 DEL PRADO BLVD S
CAPE CORAL FL
33990-2618
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-424-3120
  • Fax:
Mailing address:
  • Phone: 239-424-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberND11044
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.000203
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND11044
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND11044
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: