Provider Demographics
NPI:1659855765
Name:WHITE, LYDIA DELBRIDGE
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:DELBRIDGE
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 BRIARCLIFF RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-4010
Mailing Address - Country:US
Mailing Address - Phone:404-785-2769
Mailing Address - Fax:
Practice Address - Street 1:1920 BRIARCLIFF RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-4010
Practice Address - Country:US
Practice Address - Phone:404-785-2769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003762133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric