Healthcare Provider Details

I. General information

NPI: 1730368671
Provider Name (Legal Business Name): TAMMY ELVA GRAYUM RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2007
Last Update Date: 10/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14171 STATE ROAD TT
FESTUS MO
63028-4819
US

IV. Provider business mailing address

14171 STATE ROAD TT
FESTUS MO
63028-4819
US

V. Phone/Fax

Practice location:
  • Phone: 573-513-5380
  • Fax:
Mailing address:
  • Phone: 573-513-5380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number2004024027
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: