Healthcare Provider Details

I. General information

NPI: 1245100775
Provider Name (Legal Business Name): NOURISHED ROOTS CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 NEWCASTLE ST
BRUNSWICK GA
31520-7019
US

IV. Provider business mailing address

1405 NEWCASTLE ST
BRUNSWICK GA
31520-7019
US

V. Phone/Fax

Practice location:
  • Phone: 912-515-5822
  • Fax: 833-923-1244
Mailing address:
  • Phone: 912-515-5822
  • Fax: 833-923-1244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: CASSANDRA DEFEO
Title or Position: OWNER
Credential:
Phone: 912-515-5822