Healthcare Provider Details

I. General information

NPI: 1285040386
Provider Name (Legal Business Name): PRESCRIPTIVE NUTRITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 08/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 W MAIN ST
RUSSELLVILLE AR
72801-2301
US

IV. Provider business mailing address

3205 W MAIN ST
RUSSELLVILLE AR
72801-2301
US

V. Phone/Fax

Practice location:
  • Phone: 479-651-8547
  • Fax:
Mailing address:
  • Phone: 479-651-8547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number0449
License Number StateAR

VIII. Authorized Official

Name: MRS. GINA ANNE KERSH
Title or Position: REGISTERED DIETITIAN, NUTRITIONIST
Credential: RDN, LD
Phone: 479-651-8547