Healthcare Provider Details

I. General information

NPI: 1386379071
Provider Name (Legal Business Name): EAST TN NUTRITION AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/24/2022
Certification Date: 07/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PROSPERITY DR
KNOXVILLE TN
37923-4718
US

IV. Provider business mailing address

3420 NEW CORINTH RD
BLAINE TN
37709-5623
US

V. Phone/Fax

Practice location:
  • Phone: 865-290-0110
  • Fax: 865-290-0140
Mailing address:
  • Phone: 865-712-4428
  • Fax: 865-290-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: KRYSTAL CAMERON
Title or Position: REGISTERED DIETITIAN/OWNER
Credential: RD, LDN
Phone: 865-712-4428