=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780813733
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA ROSE TALLEDA R.D., L.D./N, CIEC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2009
-----------------------------------------------------
Last Update Date | 10/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1448 CHURCHILL CIR # S204
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34116-3613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-338-7420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1448 CHURCHILL CIR # S204
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34116-3613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-338-7420
-----------------------------------------------------
Fax | 239-433-6703
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | ND5196
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | ND5196
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------