=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730753013
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMMIE LEDWELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2021
-----------------------------------------------------
Last Update Date | 05/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 PARKVIEW DR STE 220
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76102-5824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-864-8898
-----------------------------------------------------
Fax | 682-747-6836
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6501 TOPAZ DR
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76001-7462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-864-8898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------