Provider Demographics
NPI:1558382556
Name:GRIMSLEY, MARTHA D (RD,LD)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:D
Last Name:GRIMSLEY
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 CLAIRMONT RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4004
Mailing Address - Country:US
Mailing Address - Phone:404-321-6111
Mailing Address - Fax:
Practice Address - Street 1:3191 CRESTMONT WAY NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4679
Practice Address - Country:US
Practice Address - Phone:770-499-9319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000219133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALD000219Medicare UPIN