Healthcare Provider Details

I. General information

NPI: 1356133854
Provider Name (Legal Business Name): JOHN COSPER KITTRELL RDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

993 JOHNSON FERRY RD STE D250
ATLANTA GA
30342-1646
US

IV. Provider business mailing address

654 HORSE FERRY RD
LAWRENCEVILLE GA
30044-5606
US

V. Phone/Fax

Practice location:
  • Phone: 404-236-8036
  • Fax:
Mailing address:
  • Phone: 706-818-2629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License Number86253404
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: