Provider Demographics
NPI:1437102530
Name:DECAILLE, DONNA P (RD)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:P
Last Name:DECAILLE
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 1:1922 HIGHWAY 74 N
Mailing Address - Street 2:SUITE D
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-1660
Mailing Address - Country:US
Mailing Address - Phone:404-797-0528
Mailing Address - Fax:678-489-8957
Practice Address - Street 1:1922 HIGHWAY 74 N
Practice Address - Street 2:SUITE D
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-1660
Practice Address - Country:US
Practice Address - Phone:404-797-0528
Practice Address - Fax:678-489-8957
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002627133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA24020797AMedicaid
GA24020797AMedicaid