Healthcare Provider Details

I. General information

NPI: 1689004160
Provider Name (Legal Business Name): VIRGINIA CARNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 DANNY THOMAS PLACE - MAIL STOP 732
MEMPHIS TN
38105
US

IV. Provider business mailing address

90 GROVE DALE ST
MEMPHIS TN
38120-2010
US

V. Phone/Fax

Practice location:
  • Phone: 901-595-3315
  • Fax:
Mailing address:
  • Phone: 901-595-3315
  • Fax: 901-595-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number000471
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: