Provider Demographics
NPI:1275110959
Name:SPEK, MADISON RAQUEL (RD)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:RAQUEL
Last Name:SPEK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5004 BRENDLYNN DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7656
Mailing Address - Country:US
Mailing Address - Phone:404-447-9701
Mailing Address - Fax:
Practice Address - Street 1:5004 BRENDLYNN DR
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-7656
Practice Address - Country:US
Practice Address - Phone:404-447-9701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered