Provider Demographics
NPI:1053323675
Name:HARRIS, GWENDOLYN ROSE (RD)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:ROSE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4230 SORRELLS BLVD
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-4047
Mailing Address - Country:US
Mailing Address - Phone:678-567-1928
Mailing Address - Fax:
Practice Address - Street 1:4 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:ELBERTON
Practice Address - State:GA
Practice Address - Zip Code:30635-1830
Practice Address - Country:US
Practice Address - Phone:706-283-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001609133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered