Healthcare Provider Details

I. General information

NPI: 1710036454
Provider Name (Legal Business Name): TAMMY JIMENEZ RD, LD, IBCLC, CPM,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 10/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 W. TWIN LAKES DR.
TYLER TX
75704
US

IV. Provider business mailing address

5555 W TWIN LAKES DR.
TYLER TX
75704
US

V. Phone/Fax

Practice location:
  • Phone: 409-382-7040
  • Fax: 903-496-0361
Mailing address:
  • Phone: 409-382-7040
  • Fax: 903-496-0361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT07165
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-17418
License Number State
# 4
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number99311
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: