Healthcare Provider Details

I. General information

NPI: 1821628223
Provider Name (Legal Business Name): ALICE POWELL TAYLOR R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ST. DOMINIC WEIGHT LOSS SOLUTIONS 3800 INTERSTATE 55 NORTH FRONTAGE ROAD SUITE 102
JACKSON MS
39211
US

IV. Provider business mailing address

131 WOODLANDS GREEN DR
BRANDON MS
39047-8773
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-6872
  • Fax:
Mailing address:
  • Phone: 601-954-5727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License NumberD0219
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberD0219
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: