Provider Demographics
NPI:1619946704
Name:ALLEN, LEANETTA (RD)
Entity Type:Individual
Prefix:
First Name:LEANETTA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
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:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-423-8697
Mailing Address - Fax:731-422-5743
Practice Address - Street 1:700 W FOREST AVE
Practice Address - Street 2:STE 300
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3937
Practice Address - Country:US
Practice Address - Phone:731-422-0330
Practice Address - Fax:731-422-0220
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRD1307133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00092732Medicare PIN
TN3240490Medicare PIN