Provider Demographics
NPI:1699432096
Name:WICKS, EMMA LOUISE (MS RD LD CIEC)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:LOUISE
Last Name:WICKS
Suffix:
Gender:F
Credentials:MS RD LD CIEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5198 WADDELL HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-9433
Mailing Address - Country:US
Mailing Address - Phone:615-305-8110
Mailing Address - Fax:
Practice Address - Street 1:1905 CHERRY HILL DR STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5812
Practice Address - Country:US
Practice Address - Phone:573-343-4017
Practice Address - Fax:573-615-4443
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4152133V00000X
MN5324133V00000X
MO2021038178133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered