Provider Demographics
NPI:1992560791
Name:WICKLIFFE, ELIZABETH WARREN
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:WARREN
Last Name:WICKLIFFE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:WICKLIFFE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDN, LDN
Mailing Address - Street 1:2193 GLENBAR DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38139-5418
Mailing Address - Country:US
Mailing Address - Phone:901-218-9516
Mailing Address - Fax:
Practice Address - Street 1:2193 GLENBAR DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38139-5418
Practice Address - Country:US
Practice Address - Phone:901-218-9516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000002650133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered