Basic Information
Provider Information | |||||||||
NPI: | 1144468216 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAM | ||||||||
FirstName: | EMILY | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CDE | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WIGHT | ||||||||
OtherFirstName: | EMILY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CDE | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9 | ||||||||
Address2: |   | ||||||||
City: | KINGSPORT | ||||||||
State: | TN | ||||||||
PostalCode: | 376620009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4238572066 | ||||||||
FaxNumber: | 4238572030 | ||||||||
Practice Location | |||||||||
Address1: | 105 W STONE DR | ||||||||
Address2: | STE 2D | ||||||||
City: | KINGSPORT | ||||||||
State: | TN | ||||||||
PostalCode: | 376603256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4235781588 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/28/2009 | ||||||||
LastUpdateDate: | 01/28/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | 2041 | TN | Y |   | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
No ID Information.