Provider Demographics
NPI:1811632474
Name:MALDONADO, LIANNI (RD)
Entity type:Individual
Prefix:
First Name:LIANNI
Middle Name:
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4424 ROXBURY DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3252
Mailing Address - Country:US
Mailing Address - Phone:770-656-6367
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST # AD2254
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-446-1251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD005424133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered