Healthcare Provider Details

I. General information

NPI: 1205654787
Provider Name (Legal Business Name): KERIN TAMARA MCCALLISTER MS, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 LAWRENCEVILLE SUWANEE RD STE 108
SUWANEE GA
30024-2628
US

IV. Provider business mailing address

1461 DORCHESTER DR
LAWRENCEVILLE GA
30043-4354
US

V. Phone/Fax

Practice location:
  • Phone: 678-787-3058
  • Fax:
Mailing address:
  • Phone: 678-787-3058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: