Provider Demographics
NPI:1508458878
Name:GRAY, FREDRICK TAWONE (RD)
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:TAWONE
Last Name:GRAY
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7535 BARTLETT CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-8952
Mailing Address - Country:US
Mailing Address - Phone:901-377-3010
Mailing Address - Fax:901-377-4999
Practice Address - Street 1:7535 BARTLETT CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-8952
Practice Address - Country:US
Practice Address - Phone:901-377-3010
Practice Address - Fax:901-377-4999
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN86041493133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered