MEDICARE: MS. SHALESE MCMILLAN PUGH RD,LD

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	LD002976	GA

General Provider Information

NPI Number	:	1447245345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHALESE MCMILLAN PUGH RD,LD

Provider Business Mailing Address
First Line	:	7441 MISTYDAWN DR
Second Line	:
City	:	FAIRBURN
State	:	GA
Zip	:	30213-4331
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4772 FRONTAGE RD
Second Line	:
City	:	FOREST PARK
State	:	GA
Zip	:	30297-1606
Country	:	US
Telephone Number	:	919-491-9028
Fax Number	:

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

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	04/23/2024

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