Provider Demographics
NPI:1548366289
Name:TITTLE, PATRICIA LYNN (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:LYNN
Last Name:TITTLE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E SUE DR
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MO
Mailing Address - Zip Code:63863-9516
Mailing Address - Country:US
Mailing Address - Phone:573-276-4357
Mailing Address - Fax:
Practice Address - Street 1:1500 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3318
Practice Address - Country:US
Practice Address - Phone:573-686-4151
Practice Address - Fax:573-778-4161
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001022421133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered