Provider Demographics
NPI:1467335786
Name:MISTY CLACKUM NUTRITION LLC
Entity type:Organization
Organization Name:MISTY CLACKUM NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:MULLINS
Authorized Official - Last Name:CLACKUM
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CSP, LDN
Authorized Official - Phone:423-284-5512
Mailing Address - Street 1:1814 TREESORT VW
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-5383
Mailing Address - Country:US
Mailing Address - Phone:423-284-5512
Mailing Address - Fax:770-470-0770
Practice Address - Street 1:1814 TREESORT VW
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-5383
Practice Address - Country:US
Practice Address - Phone:423-284-5512
Practice Address - Fax:770-470-0770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-26
Last Update Date:2025-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Multi-Specialty
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight ManagementGroup - Multi-Specialty