Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | XOO 6115-1 | NY |
NPI | 1215022538 |
---|---|
Provider Name | Dr. Jill R Tieman |
First Address | Bayport, NY 11705-1607 |
Second Address | Bayport, NY 11705-1607 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2006 |
Last Update Date | 08/07/2007 |