Provider Demographics
NPI:1720441827
Name:BENNETT, ASHLEY (MA, RDN, LD)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MA, RDN, LD
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:SKORCZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, RDN, LD
Mailing Address - Street 1:2115 SUGARSTONE CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5055
Mailing Address - Country:US
Mailing Address - Phone:770-380-4451
Mailing Address - Fax:
Practice Address - Street 1:2115 SUGARSTONE CT
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5055
Practice Address - Country:US
Practice Address - Phone:770-380-4451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003854133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered