Provider Demographics
NPI:1174757868
Name:ORTIZ, TANYA (LICENSED DIETITIAN)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:LICENSED DIETITIAN
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:LUTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICENSED DIETITIAN
Mailing Address - Street 1:2220 LEMP AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2700
Mailing Address - Country:US
Mailing Address - Phone:314-814-8556
Mailing Address - Fax:314-814-8542
Practice Address - Street 1:2200 LEMP
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104
Practice Address - Country:US
Practice Address - Phone:314-814-8556
Practice Address - Fax:314-814-8542
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004008861133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO821180422Medicare PIN