Healthcare Provider Details

I. General information

NPI: 1538332663
Provider Name (Legal Business Name): MARY LAUREN WHITESIDE R.D, C.S.P, L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 WATERS AVE FOOD & NUTRITION SERVICES
SAVANNAH GA
31404-6220
US

IV. Provider business mailing address

4700 WATERS AVE P.O. BOX 23089
SAVANNAH GA
31404-6220
US

V. Phone/Fax

Practice location:
  • Phone: 912-350-9473
  • Fax: 843-350-9557
Mailing address:
  • Phone: 912-350-9473
  • Fax: 843-350-9557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number160
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number003750
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: