Healthcare Provider Details

I. General information

NPI: 1518051754
Provider Name (Legal Business Name): TIFFANY A KERNS RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 SW MACADAM AVE STE 580
PORTLAND OR
97239-3837
US

IV. Provider business mailing address

5200 SW MACADAM AVE STE 580
PORTLAND OR
97239-3837
US

V. Phone/Fax

Practice location:
  • Phone: 503-231-7854
  • Fax: 503-231-8153
Mailing address:
  • Phone: 503-231-7854
  • Fax: 503-231-8153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number448
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: