Healthcare Provider Details

I. General information

NPI: 1568153559
Provider Name (Legal Business Name): ALICE KEMP CORREA RD, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALICE RUTH KEMP RD, RN

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

993 JOHNSON FERRY RD # D
ATLANTA GA
30342-1620
US

IV. Provider business mailing address

1682 TAILMORE LN
LAWRENCEVILLE GA
30043-7864
US

V. Phone/Fax

Practice location:
  • Phone: 404-236-8036
  • Fax: 404-236-8267
Mailing address:
  • Phone: 678-462-2489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number004478
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: