Provider Demographics
NPI:1013489871
Name:KING, EMILY SELPH (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:SELPH
Last Name:KING
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:LAUREN
Other - Last Name:SELPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:902 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3270
Mailing Address - Country:US
Mailing Address - Phone:229-276-3375
Mailing Address - Fax:
Practice Address - Street 1:902 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3270
Practice Address - Country:US
Practice Address - Phone:229-276-3375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD005255133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered