Healthcare Provider Details

I. General information

NPI: 1053979690
Provider Name (Legal Business Name): VANESSA LYNN HUNT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4276 COURTSIDE DR
STONE MOUNTAIN GA
30083-1292
US

IV. Provider business mailing address

PO BOX 382
SCOTTDALE GA
30079-0382
US

V. Phone/Fax

Practice location:
  • Phone: 404-819-4316
  • Fax:
Mailing address:
  • Phone: 404-819-4316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberLD002355
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: