Healthcare Provider Details

I. General information

NPI: 1972969475
Provider Name (Legal Business Name): NELLIE ROVANSEK RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2219 DARTMOUTH RD
AUGUSTA GA
30904-3429
US

IV. Provider business mailing address

551 NATIONAL HEALTH CARE DR
DAYTONA BEACH FL
32114-1495
US

V. Phone/Fax

Practice location:
  • Phone: 706-414-4104
  • Fax:
Mailing address:
  • Phone: 407-664-0444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD003932
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: