Provider Demographics
NPI:1730368671
Name:GRAYUM, TAMMY ELVA (RD, LD)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:ELVA
Last Name:GRAYUM
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14171 STATE ROAD TT
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4819
Mailing Address - Country:US
Mailing Address - Phone:573-513-5380
Mailing Address - Fax:
Practice Address - Street 1:14171 STATE ROAD TT
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4819
Practice Address - Country:US
Practice Address - Phone:573-513-5380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-28
Last Update Date:2007-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004024027133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic