Provider Demographics
NPI:1598564718
Name:RUNNELS, MILLICENT (RDN)
Entity type:Individual
Prefix:
First Name:MILLICENT
Middle Name:
Last Name:RUNNELS
Suffix:
Gender:
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:842 SHADDEN RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4239
Mailing Address - Country:US
Mailing Address - Phone:423-262-3061
Mailing Address - Fax:
Practice Address - Street 1:842 SHADDEN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4239
Practice Address - Country:US
Practice Address - Phone:423-262-3061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN86373357133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered