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General NPI Number Information
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NPI Number | 1477616951
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Entity Type | Individual
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Provider Name | MARY D WALTERS RD, LD
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Gender | Female
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1329 PORTMAN DR SE STE. D
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City | CONYERS
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State | GA
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Zip | 30094-6619
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Country | US
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Telephone | 770-785-5936
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 897
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-0897
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Country | US
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Telephone | 770-339-4260
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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 | LD000571
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License Number State | GA
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