=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639203250
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYN BROOKS-TAYLOR MAT, RD, LDN, CHFS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 01/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2491 BROOKS RD
-----------------------------------------------------
City | BELDEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38826-9548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-397-6053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2491 BROOKS RD
-----------------------------------------------------
City | BELDEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38826-9548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-397-6053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | LDN1336
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | D0455
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------