Provider Demographics
NPI:1821471152
Name:EARWOOD, GRETCHEN
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:EARWOOD
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 1:17 CREEKVIEW DR SE
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-6988
Mailing Address - Country:US
Mailing Address - Phone:770-607-6401
Mailing Address - Fax:
Practice Address - Street 1:750 TOWNPARK LN NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5579
Practice Address - Country:US
Practice Address - Phone:770-514-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001916133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered