Provider Demographics
NPI:1073944492
Name:CLACKUM, MISTY MULLINS (RD, CSP, LDN)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:MULLINS
Last Name:CLACKUM
Suffix:
Gender:F
Credentials:RD, CSP, LDN
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:LEHE
Other - Last Name:MULLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CSP, LDN
Mailing Address - Street 1:3869 BERKSHIRE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-4560
Mailing Address - Country:US
Mailing Address - Phone:423-284-5512
Mailing Address - Fax:
Practice Address - Street 1:3869 BERKSHIRE RIDGE DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-4560
Practice Address - Country:US
Practice Address - Phone:423-284-5512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002340133V00000X, 133VN1401X, 133VN1004X
TN1250133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1401XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ038482Medicaid