MEDICARE: ALEXANDRA RENEA NUSSBAUMER GARDNER RDN, LDN, CLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	4200	TN

General Provider Information

NPI Number	:	1750049995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRA RENEA NUSSBAUMER GARDNER RDN, LDN, CLC

Provider Business Mailing Address
First Line	:	829 S CIRCLE DR APT 110D
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-2338
Country	:	US
Telephone Number	:	865-659-1696
Fax Number	:

Provider Business Practice Location Address
First Line	:	6829 MOUNTAIN SHADOW DR
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37918-6317
Country	:	US
Telephone Number	:	865-659-1696
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2021
Last Update Date	:	02/16/2023

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