Provider Demographics
NPI:1780838920
Name:PICKLESIMER, AUDREY L (MS,RD,LDN)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:L
Last Name:PICKLESIMER
Suffix:
Gender:F
Credentials:MS,RD,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8948 LONG SAVANNAH RD
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-5702
Mailing Address - Country:US
Mailing Address - Phone:423-339-1415
Mailing Address - Fax:423-339-1715
Practice Address - Street 1:8948 LONG SAVANNAH RD
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-5702
Practice Address - Country:US
Practice Address - Phone:423-339-1415
Practice Address - Fax:423-339-1715
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1960133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGOtherNON APPLICABLE