Provider Demographics
NPI:1558814640
Name:ROBERTS, ELAYNA (RD)
Entity Type:Individual
Prefix:
First Name:ELAYNA
Middle Name:
Last Name:ROBERTS
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 1:1109 BURLEYSON RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3094
Mailing Address - Country:US
Mailing Address - Phone:706-272-6079
Mailing Address - Fax:706-272-6053
Practice Address - Street 1:1109 BURLEYSON RD
Practice Address - Street 2:SUITE 103
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3094
Practice Address - Country:US
Practice Address - Phone:706-272-6079
Practice Address - Fax:706-272-6053
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003850133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered