Provider Demographics
NPI:1275625089
Name:OUTLAW, JOYCE ELAINE (RD LD MS)
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:ELAINE
Last Name:OUTLAW
Suffix:
Gender:F
Credentials:RD LD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 KINGS DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2884
Mailing Address - Country:US
Mailing Address - Phone:478-272-1210
Mailing Address - Fax:
Practice Address - Street 1:1826 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-3620
Practice Address - Country:US
Practice Address - Phone:478-272-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL30336133V00000X
GALD001552133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
303362OtherREGISTERED DIETITIAN
GALD001552OtherLICENSED DIETITIAN