Provider Demographics
NPI:1790038834
Name:DAVIS, DEBORAH L (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:L
Last Name:DAVIS
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 1:545 S MAIN ST APT 401
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-4820
Mailing Address - Country:US
Mailing Address - Phone:901-523-8990
Mailing Address - Fax:
Practice Address - Street 1:1030 JEFFERSON AVE # 120
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2127
Practice Address - Country:US
Practice Address - Phone:901-523-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000002368133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
00991691OtherCOMMISSION ON DIETETIC REGISTRATION
TNLDN0000002368OtherTENNESSEE DIETETIC LICENSURE