Provider Demographics
NPI:1336867886
Name:BAZEMORE, MARY GLYNN (MS, RD, CPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GLYNN
Last Name:BAZEMORE
Suffix:
Gender:F
Credentials:MS, RD, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 PROVIDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-7565
Mailing Address - Country:US
Mailing Address - Phone:205-837-4882
Mailing Address - Fax:
Practice Address - Street 1:420 TAYLOR DR
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:GA
Practice Address - Zip Code:31029-8506
Practice Address - Country:US
Practice Address - Phone:205-837-4882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL86176913133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered