Provider Demographics
NPI:1275756918
Name:BUNYON, NORETTA GAIL (LD I)
Entity Type:Individual
Prefix:MRS
First Name:NORETTA
Middle Name:GAIL
Last Name:BUNYON
Suffix:
Gender:F
Credentials:LD I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6911 AUTUMN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-4777
Mailing Address - Country:US
Mailing Address - Phone:770-413-8151
Mailing Address - Fax:
Practice Address - Street 1:515 FAIRBURN RD SW
Practice Address - Street 2:SUITE 350
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2012
Practice Address - Country:US
Practice Address - Phone:404-505-6754
Practice Address - Fax:404-505-6758
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000612133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education