MEDICARE: TANYA RENEE LUNSFORD RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	ND14079	FL
2	133V00000X	Registered Dietitian	836192	IN
3	133V00000X	Registered Dietitian	3700100A	IN

General Provider Information

NPI Number	:	1013173707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANYA RENEE LUNSFORD RD

Provider Business Mailing Address
First Line	:	1559 INGLE RD STE A
Second Line	:
City	:	DEFUNIAK SPRINGS
State	:	FL
Zip	:	32433-5065
Country	:	US
Telephone Number	:	812-592-4061
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 MIRACLE STRIP PKWY SE UNIT 204
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-6018
Country	:	US
Telephone Number	:	850-374-7604
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2008
Last Update Date	:	05/07/2026

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