Provider Demographics
NPI:1568148948
Name:TEP-RUTKOWSKI, POUTHEAVY LAT (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:POUTHEAVY
Middle Name:LAT
Last Name:TEP-RUTKOWSKI
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:THEAVY
Other - Middle Name:LAT
Other - Last Name:TEP-RUTKOWSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:577 IVES CIR NW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-8726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2295 RONALD REAGAN PKWY STE 300
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-5739
Practice Address - Country:US
Practice Address - Phone:770-982-4115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86296100133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered