Provider Demographics
NPI:1780768663
Name:STANBACK, ELLEN SURATT (RD,LD,CLC)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:SURATT
Last Name:STANBACK
Suffix:
Gender:F
Credentials:RD,LD,CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3177 KENSINGTON RD
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-1457
Mailing Address - Country:US
Mailing Address - Phone:404-299-1150
Mailing Address - Fax:
Practice Address - Street 1:2277 STONE MOUNTAIN LITHONIA RD
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-5252
Practice Address - Country:US
Practice Address - Phone:770-484-2600
Practice Address - Fax:770-484-3830
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001907133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBMKMedicare ID - Type Unspecified
GAQ06385Medicare UPIN