Provider Demographics
NPI:1538827894
Name:ROGERS, CRYSTAL LEE (RDN, LDN)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 E CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:TN
Mailing Address - Zip Code:38355-9763
Mailing Address - Country:US
Mailing Address - Phone:731-217-5601
Mailing Address - Fax:
Practice Address - Street 1:180 OLD HICKORY BLVD STE L
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2500
Practice Address - Country:US
Practice Address - Phone:731-661-2763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4139133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered