Provider Demographics
NPI:1336753474
Name:OLDHAM, BARBARA EUTSEY
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:EUTSEY
Last Name:OLDHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:DEE
Other - Last Name:EUTSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2100 TOWNE MANOR DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2931
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4045 ORCHARD RD SE STE 230
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-4905
Practice Address - Country:US
Practice Address - Phone:770-693-8618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-05
Last Update Date:2020-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004671133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty