Provider Demographics
NPI:1356058085
Name:PENDLEY, MIRANDA NICOLE (RDN, LD)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:NICOLE
Last Name:PENDLEY
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13190 HIGHWAY 92 STE 70-90
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4415
Mailing Address - Country:US
Mailing Address - Phone:770-926-9495
Mailing Address - Fax:
Practice Address - Street 1:13190 HIGHWAY 92 STE 70-90
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4415
Practice Address - Country:US
Practice Address - Phone:770-926-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD006080133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered