Provider Demographics
NPI:1194029678
Name:KHAKI, ROSHAN N (RD,LD,CDE)
Entity Type:Individual
Prefix:
First Name:ROSHAN
Middle Name:N
Last Name:KHAKI
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 1:1505 NORTHSIDE BLVD
Mailing Address - Street 2:SUITE 2800
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7623
Mailing Address - Country:US
Mailing Address - Phone:770-886-3842
Mailing Address - Fax:770-886-3843
Practice Address - Street 1:1505 NORTHSIDE BLVD
Practice Address - Street 2:SUITE 2800
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7623
Practice Address - Country:US
Practice Address - Phone:770-886-3842
Practice Address - Fax:770-886-3843
Is Sole Proprietor?:No
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002087133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered