MEDICARE: KEIRRA SHEQUANNA CROMER-ELLIS NUTRITIONIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	LD008378	GA

General Provider Information

NPI Number	:	1417791344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEIRRA SHEQUANNA CROMER-ELLIS NUTRITIONIST

Provider Business Mailing Address
First Line	:	103 PROSPECT PATH
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-2694
Country	:	US
Telephone Number	:	470-954-6517
Fax Number	:

Provider Business Practice Location Address
First Line	:	44 DARBYS CROSSING DR STE 206H
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-6029
Country	:	US
Telephone Number	:	470-954-6517
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2024
Last Update Date	:	03/02/2026

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