Healthcare Provider Details

I. General information

NPI: 1962030221
Provider Name (Legal Business Name): ALLISON BURGE CLAYTON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N DUNLAP NUTRITION THERAPY DEPT, 1ST FLOOR RESEARCH TOWER
MEMPHIS TN
38103
US

IV. Provider business mailing address

50 N DUNLAP NUTRITION THERAPY DEPT, 1ST FLOOR RESEARCH TOWER
MEMPHIS TN
38103
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-6242
  • Fax: 901-287-5123
Mailing address:
  • Phone: 901-287-6242
  • Fax: 901-287-5123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number2599
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: