Healthcare Provider Details

I. General information

NPI: 1700123064
Provider Name (Legal Business Name): ELLAD NUTRITION CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 01/11/2025
Certification Date: 01/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9401 COURTHOUSE RD STE 202
CHESTERFIELD VA
23832-6687
US

IV. Provider business mailing address

PO BOX 2947
CHESTERFIELD VA
23832-9118
US

V. Phone/Fax

Practice location:
  • Phone: 804-616-4378
  • Fax: 804-451-4586
Mailing address:
  • Phone: 804-616-4378
  • Fax: 804-616-4378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TYRA L TANNER
Title or Position: CLINICAL DIRECTOR
Credential: DNP,ANP,CNS,MSN, RD
Phone: 804-616-4378