=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205769965
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIMPLE FAITH WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2026
-----------------------------------------------------
Last Update Date | 06/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1711 WATFORD GLN
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30043-3078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-652-6488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2296 HENDERSON MILL RD NE STE 116
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30345-2739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-652-6488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED DIETITIAN
-----------------------------------------------------
Name | KESHA CHANEL PALMER
-----------------------------------------------------
Credential | LD
-----------------------------------------------------
Telephone | 757-652-6488
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------