Healthcare Provider Details

I. General information

NPI: 1114498722
Provider Name (Legal Business Name): AUDREY GRANT NDTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2018
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD RM GC217
DECATUR GA
30033-4004
US

IV. Provider business mailing address

3344 CHASTAIN GARDENS DR NW
KENNESAW GA
30144-3745
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax:
Mailing address:
  • Phone: 404-969-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: