Provider Demographics
NPI:1912208935
Name:KATZ, ILANA (MS, RD, CSSD)
Entity Type:Individual
Prefix:
First Name:ILANA
Middle Name:
Last Name:KATZ
Suffix:
Gender:F
Credentials:MS, RD, CSSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3686 ASHFORD CREEK TRL NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-5055
Mailing Address - Country:US
Mailing Address - Phone:770-458-2127
Mailing Address - Fax:
Practice Address - Street 1:3686 ASHFORD CREEK TRL NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-5055
Practice Address - Country:US
Practice Address - Phone:770-458-2127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002705133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered