Healthcare Provider Details

I. General information

NPI: 1447872486
Provider Name (Legal Business Name): LINDSAY SPIVEY PETTY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 CEDAR CREEK CT
FAYETTEVILLE GA
30215-2799
US

IV. Provider business mailing address

190 CEDAR CREEK CT
FAYETTEVILLE GA
30215-2799
US

V. Phone/Fax

Practice location:
  • Phone: 478-278-0641
  • Fax:
Mailing address:
  • Phone: 478-278-0641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: