Healthcare Provider Details

I. General information

NPI: 1447161864
Provider Name (Legal Business Name): SALLY SMITH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9077 ASHMERE DR
GERMANTOWN TN
38139-6645
US

IV. Provider business mailing address

9077 ASHMERE DR
GERMANTOWN TN
38139-6645
US

V. Phone/Fax

Practice location:
  • Phone: 901-299-3324
  • Fax:
Mailing address:
  • Phone: 901-299-3324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3216
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: