Healthcare Provider Details

I. General information

NPI: 1619946704
Provider Name (Legal Business Name): LEANETTA ALLEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W FOREST AVE STE 300
JACKSON TN
38301-3937
US

IV. Provider business mailing address

PO BOX 400
JACKSON TN
38302-0400
US

V. Phone/Fax

Practice location:
  • Phone: 731-422-0330
  • Fax: 731-422-0220
Mailing address:
  • Phone: 731-423-8697
  • Fax: 731-422-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberRD1307
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: