Healthcare Provider Details

I. General information

NPI: 1912686437
Provider Name (Legal Business Name): CRYSTAL MICHELLE DUQUE RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CRYSTAL MICHELLE DUQUE RDN

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12236 MADISON DR
ATLANTA GA
30346-2472
US

IV. Provider business mailing address

260 PEACHTREE ST NW
ATLANTA GA
30303-1202
US

V. Phone/Fax

Practice location:
  • Phone: 423-737-8015
  • Fax:
Mailing address:
  • Phone: 423-737-8015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberLD009627
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT88281
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: