Basic Information
| Provider Information | |||||||||
| NPI: | 1790038834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MS, RD, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 545 S MAIN ST APT 401 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381034820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015238990 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1030 JEFFERSON AVE # 120 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381042127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015238990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2012 | ||||||||
| LastUpdateDate: | 10/25/2012 | ||||||||
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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 | LDN0000002368 | TN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 00991691 | 01 | COMMISSION ON DIETETIC REGISTRATION | OTHER | LDN0000002368 | 01 | TN | TENNESSEE DIETETIC LICENSURE | OTHER |