Healthcare Provider Details

I. General information

NPI: 1255240040
Provider Name (Legal Business Name): COURTNEY ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY THIEDE

II. Dates (important events)

Enumeration Date: 09/05/2026
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

581 HAILEY RIDGE LN
GAINESBORO TN
38562-4906
US

IV. Provider business mailing address

581 HAILEY RIDGE LN
GAINESBORO TN
38562-4906
US

V. Phone/Fax

Practice location:
  • Phone: 707-766-4287
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4141
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: