Provider Demographics
NPI:1073139994
Name:ADDISON, SARA ROSE (MS, RD, LD)
Entity Type:Individual
Prefix:MS
First Name:SARA
Middle Name:ROSE
Last Name:ADDISON
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 DALLAS HWY
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1202
Mailing Address - Country:US
Mailing Address - Phone:770-812-3249
Mailing Address - Fax:
Practice Address - Street 1:601 DALLAS HWY
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1202
Practice Address - Country:US
Practice Address - Phone:770-812-3249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003685133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered