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General NPI Number Information
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NPI Number | 1285040386
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Entity Type | Organization
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Legal Business Name | PRESCRIPTIVE NUTRITION, LLC
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Dates
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Enumeration Date | 07/09/2014
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Last Update Date | 08/15/2014
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Provider Practice Location Address
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Address Line | 3205 W MAIN ST
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City | RUSSELLVILLE
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State | AR
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Zip | 72801-2301
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Country | US
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Telephone | 479-651-8547
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Fax |
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Provider Business Mailing Address
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Address Line | 3205 W MAIN ST
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City | RUSSELLVILLE
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State | AR
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Zip | 72801-2301
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Country | US
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Telephone | 479-651-8547
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Fax |
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Authorized Official
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Title or Position | REGISTERED DIETITIAN, NUTRITIONIST
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Name | MRS. GINA ANNE KERSH
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Credential | RDN, LD
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Telephone | 479-651-8547
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133N00000X
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Taxonomy Name | Nutritionist
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License Number | 0449
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License Number State | AR
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