=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740485861
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMARA MOODY RD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2007
-----------------------------------------------------
Last Update Date | 08/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 969 GARDNER RD
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38449-3374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-321-1787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 969 GARDNER RD
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38449-3374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-321-1787
-----------------------------------------------------
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 | 5876
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------