Healthcare Provider Details

I. General information

NPI: 1962467928
Provider Name (Legal Business Name): MAVIS J ONKS RD,LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FIRST STREET BLD 200 BOX 4000 JAMES H QUILLEN VAMC(120B)
MOUNTAIN HOME TN
37684-4000
US

IV. Provider business mailing address

450 MOUNTAIN LIGHT LN
UNICOI TN
37692-4772
US

V. Phone/Fax

Practice location:
  • Phone: 423-926-1171
  • Fax: 423-979-3402
Mailing address:
  • Phone: 423-926-1171
  • Fax: 423-979-3402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number00121
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: