Provider Demographics
NPI:1821628223
Name:TAYLOR, ALICE POWELL (RD)
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:POWELL
Last Name:TAYLOR
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 1:131 WOODLANDS GREEN DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8773
Mailing Address - Country:US
Mailing Address - Phone:601-954-5727
Mailing Address - Fax:
Practice Address - Street 1:ST. DOMINIC WEIGHT LOSS SOLUTIONS
Practice Address - Street 2:3800 INTERSTATE 55 NORTH FRONTAGE ROAD SUITE 102
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211
Practice Address - Country:US
Practice Address - Phone:601-200-6872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD0219133VN1301X, 133VN1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
No133VN1301XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSD0219OtherREGISTERED DIETITIAN LICENSE
690960OtherCOMMISSION ON DIETETIC REGISTRATION/ACADEMY OF NUTRITION AND DIETETICS