Healthcare Provider Details

I. General information

NPI: 1487873352
Provider Name (Legal Business Name): CYNTHIA GOUDEAU RD,LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 NISKEY COVE RD SW
ATLANTA GA
30331-6339
US

IV. Provider business mailing address

1830 NISKEY COVE RD SW
ATLANTA GA
30331-6339
US

V. Phone/Fax

Practice location:
  • Phone: 678-313-4620
  • Fax:
Mailing address:
  • Phone: 678-313-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberLD002849
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: