Healthcare Provider Details

I. General information

NPI: 1467292441
Provider Name (Legal Business Name): TIFFANY CICCHETTI MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 GREENS CREEK RD
GRANTS PASS OR
97527-4415
US

IV. Provider business mailing address

715 GREENS CREEK RD
GRANTS PASS OR
97527-4415
US

V. Phone/Fax

Practice location:
  • Phone: 509-570-4443
  • Fax:
Mailing address:
  • Phone: 509-570-4443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number800427
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: