Provider Demographics
NPI:1275752925
Name:STEWART, MARY ASHLEY (RD, LD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ASHLEY
Last Name:STEWART
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 1:2119 BARBERRY DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-3432
Mailing Address - Country:US
Mailing Address - Phone:404-518-3993
Mailing Address - Fax:
Practice Address - Street 1:2701 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5918
Practice Address - Country:US
Practice Address - Phone:404-501-5398
Practice Address - Fax:404-501-1773
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002442133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBBHPMedicare ID - Type UnspecifiedMEDICAL NUTRITION THERAPY