Provider Demographics
NPI:1114498722
Name:GRANT, AUDREY (NDTR)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:NDTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3344 CHASTAIN GARDENS DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3745
Mailing Address - Country:US
Mailing Address - Phone:404-969-7300
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD RM GC217
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered