Healthcare Provider Details

I. General information

NPI: 1073944492
Provider Name (Legal Business Name): MISTY MULLINS CLACKUM RD, CSP, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISTY LEHE MULLINS RD, CSP, LDN

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 07/26/2025
Certification Date: 07/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 TREESORT VW
GAINESVILLE GA
30506-5383
US

IV. Provider business mailing address

1814 TREESORT VW
GAINESVILLE GA
30506-5383
US

V. Phone/Fax

Practice location:
  • Phone: 423-284-5512
  • Fax: 770-470-0770
Mailing address:
  • Phone: 423-284-5512
  • Fax: 770-470-0770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number1250
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberLD002340
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code133VN1401X
TaxonomyPediatric Critical Care Nutrition Registered Dietitian
License NumberLD002340
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD002340
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: