Healthcare Provider Details

I. General information

NPI: 1356079792
Provider Name (Legal Business Name): ASHTON NICOLE DANIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 FOSTER RD
ROCKY TOP TN
37769-5559
US

IV. Provider business mailing address

694 DEER LODGE HWY
SUNBRIGHT TN
37872-2910
US

V. Phone/Fax

Practice location:
  • Phone: 423-319-7763
  • Fax:
Mailing address:
  • Phone: 423-319-7763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4563
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: