Provider Demographics
NPI:1891473492
Name:KELLUM, KRISTA FAIRCLOTH (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:FAIRCLOTH
Last Name:KELLUM
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:KRIST
Other - Middle Name:LAUREN
Other - Last Name:FAIRCLOTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LDN
Mailing Address - Street 1:2504 PRAIRIE HILL DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-3682
Mailing Address - Country:US
Mailing Address - Phone:912-294-7630
Mailing Address - Fax:
Practice Address - Street 1:2504 PRAIRIE HILL DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3682
Practice Address - Country:US
Practice Address - Phone:912-294-7630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000003477133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered