Healthcare Provider Details

I. General information

NPI: 1497964670
Provider Name (Legal Business Name): FATEMA SHIRIN MS RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DRIVE
ATLANTA GA
30303
US

IV. Provider business mailing address

1013 CITADEL DR NE
ATLANTA GA
30324-3813
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-4625
  • Fax: 404-616-2422
Mailing address:
  • Phone: 404-634-5231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberLD002990
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: