Healthcare Provider Details

I. General information

NPI: 1437102530
Provider Name (Legal Business Name): DONNA P DECAILLE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 06/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1922 HIGHWAY 74 N SUITE D
TYRONE GA
30290-1660
US

IV. Provider business mailing address

1922 HIGHWAY 74 N SUITE D
TYRONE GA
30290-1660
US

V. Phone/Fax

Practice location:
  • Phone: 404-797-0528
  • Fax: 678-489-8957
Mailing address:
  • Phone: 404-797-0528
  • Fax: 678-489-8957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD002627
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: