Healthcare Provider Details

I. General information

NPI: 1871852491
Provider Name (Legal Business Name): KALI KUZNIAK RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2012
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 APPLEBY DR
ATHENS GA
30605-1748
US

IV. Provider business mailing address

145 APPLEBY DR
ATHENS GA
30605-1748
US

V. Phone/Fax

Practice location:
  • Phone: 770-856-9986
  • Fax:
Mailing address:
  • Phone: 770-856-9986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD003818
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: