Provider Demographics
NPI:1487907069
Name:OLIVA, TARA JEANINE (MPH, MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:JEANINE
Last Name:OLIVA
Suffix:
Gender:F
Credentials:MPH, MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12023 S 71ST CT
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1542
Mailing Address - Country:US
Mailing Address - Phone:708-207-4224
Mailing Address - Fax:
Practice Address - Street 1:12023 S 71ST CT
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1542
Practice Address - Country:US
Practice Address - Phone:708-207-4224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-20
Last Update Date:2012-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005727133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered