Provider Demographics
NPI:1821671256
Name:KOETTER, EMILIE ELISABETH (RDN, LD)
Entity type:Individual
Prefix:
First Name:EMILIE
Middle Name:ELISABETH
Last Name:KOETTER
Suffix:
Gender:
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 1:1201 W PEACHTREE ST NW STE 2625
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3499
Mailing Address - Country:US
Mailing Address - Phone:678-371-1910
Mailing Address - Fax:
Practice Address - Street 1:704 WOODWARD CT
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-1501
Practice Address - Country:US
Practice Address - Phone:678-371-1910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.011134133V00000X
AL2947133V00000X
GALD004598133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered