Healthcare Provider Details

I. General information

NPI: 1881275113
Provider Name (Legal Business Name): CYNDY W BEAU RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 450
JACKSON MS
39216-4615
US

IV. Provider business mailing address

971 LAKELAND DR STE 450
JACKSON MS
39216-4615
US

V. Phone/Fax

Practice location:
  • Phone: 601-948-5158
  • Fax: 601-326-4265
Mailing address:
  • Phone: 601-326-4255
  • Fax: 601-228-8013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD0589
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: