Healthcare Provider Details

I. General information

NPI: 1245340058
Provider Name (Legal Business Name): ELIZABETH MARY KUSTIN M.M.SC., R.D., L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE FOOD AND NUTRITION SERVICES, RM FG-06
ATLANTA GA
30322-1059
US

IV. Provider business mailing address

1017 VISTAVIA CIR
DECATUR GA
30033-3411
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-7714
  • Fax:
Mailing address:
  • Phone: 404-634-0186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number000168
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: