Healthcare Provider Details

I. General information

NPI: 1649470345
Provider Name (Legal Business Name): HERLINE A KNIGHTS R.D, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 TRILLIUM TER
COVINGTON GA
30016-7335
US

IV. Provider business mailing address

2008 EASTVIEW PKWY SUITE 410
CONYERS GA
30013-5712
US

V. Phone/Fax

Practice location:
  • Phone: 443-992-1041
  • Fax:
Mailing address:
  • Phone: 678-616-1197
  • Fax: 678-616-1199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD003260
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: