Healthcare Provider Details

I. General information

NPI: 1720156110
Provider Name (Legal Business Name): LAURA LEE DAVIS MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 POWERS FERRY ROAD SUITE 100, BUILDING 9
MARIETTA GA
30067-5491
US

IV. Provider business mailing address

1209 NECK RD
PONTE VEDRA BEACH FL
32082-4113
US

V. Phone/Fax

Practice location:
  • Phone: 770-953-0080
  • Fax: 770-953-0031
Mailing address:
  • Phone: 678-267-4758
  • Fax: 770-953-0031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: