Provider Demographics
NPI:1629164355
Name:BRANNON, AUDREY EDWARDS (RD LD MSA, DMIN)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:EDWARDS
Last Name:BRANNON
Suffix:
Gender:F
Credentials:RD LD MSA, DMIN
Other - Prefix:MRS
Other - First Name:AUDREY
Other - Middle Name:EDWARDS
Other - Last Name:BRANNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DOCTORATE MINISTRY
Mailing Address - Street 1:1 FREEDOM WAY
Mailing Address - Street 2:296 U
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904
Mailing Address - Country:US
Mailing Address - Phone:706-733-0188
Mailing Address - Fax:
Practice Address - Street 1:1 FREEDOM WAY
Practice Address - Street 2:296 U
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904
Practice Address - Country:US
Practice Address - Phone:706-733-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALD002235OtherGA LICENSURE
GA725487OtherCDR, RD REGISTRATION NUM