Healthcare Provider Details

I. General information

NPI: 1497169189
Provider Name (Legal Business Name): KRISTIN DUGGER CUCULOVSKI RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 POWERS FERRY RD SE STE 325
ATLANTA GA
30339-5065
US

IV. Provider business mailing address

993 JOHNSON FY RD NE STE D250
ATLANTA GA
30342-1646
US

V. Phone/Fax

Practice location:
  • Phone: 404-987-1101
  • Fax:
Mailing address:
  • Phone: 404-236-8028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD004247
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License Number4247
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: