Healthcare Provider Details

I. General information

NPI: 1760398176
Provider Name (Legal Business Name): TARYN TENNYSON RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 N JACKSON ST
FORSYTH GA
31029-2168
US

IV. Provider business mailing address

4071 MADISON ACRES DR
LOCUST GROVE GA
30248-4383
US

V. Phone/Fax

Practice location:
  • Phone: 478-219-5909
  • Fax: 478-200-9588
Mailing address:
  • Phone: 678-939-2802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number889187
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: