Basic Information
| Provider Information | |||||||||
| NPI: | 1750483681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROWN | ||||||||
| FirstName: | BRIDGET | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | MS,RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9932 WOODLAND FERN DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380023809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015238990 | ||||||||
| FaxNumber: | 9015777413 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 JEFFERSON AVE | ||||||||
| Address2: | N&FS (120) | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381042127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015238990 | ||||||||
| FaxNumber: | 9015777413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1624 | TN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1624 | 01 | TN | LICENSE | OTHER |