Healthcare Provider Details

I. General information

NPI: 1467335786
Provider Name (Legal Business Name): MISTY CLACKUM NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2025
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 Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MISTY MULLINS CLACKUM
Title or Position: OWNER
Credential: RD, CSP, LDN
Phone: 423-284-5512