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General NPI Number Information
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NPI Number | 1245340058
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Entity Type | Individual
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Provider Name | ELIZABETH MARY KUSTIN M.M.SC., R.D., L.D.
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Gender | Female
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1364 CLIFTON RD NE FOOD AND NUTRITION SERVICES, RM FG-06
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City | ATLANTA
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State | GA
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Zip | 30322-1059
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Country | US
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Telephone | 404-712-7714
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Fax |
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Provider Business Mailing Address
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Address Line | 1017 VISTAVIA CIR
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City | DECATUR
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State | GA
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Zip | 30033-3411
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Country | US
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Telephone | 404-634-0186
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 000168
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License Number State | GA
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