Healthcare Provider Details

I. General information

NPI: 1417851247
Provider Name (Legal Business Name): KRISTINA EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 PEACHTREE ST NW
ATLANTA GA
30303-1202
US

IV. Provider business mailing address

245 E TRINITY PL UNIT 1504
DECATUR GA
30030-3497
US

V. Phone/Fax

Practice location:
  • Phone: 512-693-7045
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86294430
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: