Healthcare Provider Details

I. General information

NPI: 1013125061
Provider Name (Legal Business Name): ANNE DOLORES GRIDER IBCLC, RLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 11/23/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3979 EBENEZER RD
MARIETTA GA
30066-2743
US

IV. Provider business mailing address

3979 EBENEZER RD
MARIETTA GA
30066-2743
US

V. Phone/Fax

Practice location:
  • Phone: 770-516-6754
  • Fax:
Mailing address:
  • Phone: 770-516-6754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: