Provider Demographics
NPI:1356358956
Name:KOMAR, SHAYNA JEANNE (RD LD)
Entity type:Individual
Prefix:MRS
First Name:SHAYNA
Middle Name:JEANNE
Last Name:KOMAR
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:296 POCONO CT NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1067
Mailing Address - Country:US
Mailing Address - Phone:678-797-9056
Mailing Address - Fax:678-429-4261
Practice Address - Street 1:980 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 900
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1626
Practice Address - Country:US
Practice Address - Phone:678-420-4123
Practice Address - Fax:678-420-4261
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002390133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBBMQMedicare ID - Type UnspecifiedREGISTERED/LICENSED