Provider Demographics
NPI:1124369913
Name:MICKENS, NATASHA LYNN (RD, LD, CDE)
Entity Type:Individual
Prefix:MS
First Name:NATASHA
Middle Name:LYNN
Last Name:MICKENS
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 CLIFTON RD NE
Mailing Address - Street 2:SUITE 508
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-4200
Mailing Address - Country:US
Mailing Address - Phone:404-778-2850
Mailing Address - Fax:404-778-2855
Practice Address - Street 1:1525 CLIFTON RD NE
Practice Address - Street 2:SUITE 508
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-4200
Practice Address - Country:US
Practice Address - Phone:404-778-2850
Practice Address - Fax:404-778-2855
Is Sole Proprietor?:No
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003076133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered