Provider Demographics
NPI:1093709347
Name:EGART, GWENNA LYNN (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:GWENNA
Middle Name:LYNN
Last Name:EGART
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 SALEM RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4780
Mailing Address - Country:US
Mailing Address - Phone:770-954-4597
Mailing Address - Fax:
Practice Address - Street 1:122A GORDON COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-5740
Practice Address - Country:US
Practice Address - Phone:706-298-1510
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001186133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered