Healthcare Provider Details

I. General information

NPI: 1740605641
Provider Name (Legal Business Name): TIFFANY GLENN M.S., R.D., L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2014
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CASA DEL RANCHO RD
LORENA TX
76655-3179
US

IV. Provider business mailing address

500 CASA DEL RANCHO RD
LORENA TX
76655-3179
US

V. Phone/Fax

Practice location:
  • Phone: 254-716-0332
  • Fax:
Mailing address:
  • Phone: 254-716-0332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT03912
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: