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General NPI Number Information
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NPI Number | 1467335786
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Entity Type | Organization
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Legal Business Name | MISTY CLACKUM NUTRITION LLC
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Dates
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Enumeration Date | 07/26/2025
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Last Update Date | 07/26/2025
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Provider Practice Location Address
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Address Line | 1814 TREESORT VW
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City | GAINESVILLE
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State | GA
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Zip | 30506-5383
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Country | US
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Telephone | 423-284-5512
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Fax | 770-470-0770
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Provider Business Mailing Address
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Address Line | 1814 TREESORT VW
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City | GAINESVILLE
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State | GA
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Zip | 30506-5383
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Country | US
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Telephone | 423-284-5512
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Fax | 770-470-0770
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Authorized Official
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Title or Position | OWNER
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Name | MISTY MULLINS CLACKUM
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Credential | RD, CSP, LDN
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Telephone | 423-284-5512
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133VN1004X
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Taxonomy Name | Pediatric Nutrition Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 133VN1201X
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Taxonomy Name | Obesity and Weight Management Nutrition Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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