Provider Demographics
NPI:1972105070
Name:KEITH, BETHANY LYNN (MS, RDN, LD, CNSC)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:LYNN
Last Name:KEITH
Suffix:
Gender:F
Credentials:MS, RDN, LD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 DOGWOOD RD STE B2002319
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-7218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 DOGWOOD RD STE B2002319
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-7218
Practice Address - Country:US
Practice Address - Phone:770-284-0518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133VN1005X
GALD005127133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered