Healthcare Provider Details

I. General information

NPI: 1447540406
Provider Name (Legal Business Name): ELIZABETH MCKINLEY R.D., L.D., NSCA-CPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 GEORGETOWN ST
HAZLEHURST MS
39083-2805
US

IV. Provider business mailing address

405 GEORGETOWN ST
HAZLEHURST MS
39083-2805
US

V. Phone/Fax

Practice location:
  • Phone: 601-946-8236
  • Fax:
Mailing address:
  • Phone: 601-946-8236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: