=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649470345
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HERLINE A KNIGHTS R.D, LD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2007
-----------------------------------------------------
Last Update Date | 08/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 TRILLIUM TER
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30016-7335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-992-1041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2008 EASTVIEW PKWY SUITE 410
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30013-5712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-616-1197
-----------------------------------------------------
Fax | 678-616-1199
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | LD003260
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------