Healthcare Provider Details

I. General information

NPI: 1740485861
Provider Name (Legal Business Name): TAMARA MOODY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 GARDNER RD
ARDMORE TN
38449-3374
US

IV. Provider business mailing address

969 GARDNER RD
ARDMORE TN
38449-3374
US

V. Phone/Fax

Practice location:
  • Phone: 256-321-1787
  • Fax:
Mailing address:
  • Phone: 256-321-1787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number5876
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: