Provider Demographics
NPI:1982055224
Name:WASHINGTON, BEVERLY ANN (MED,RDN, CDE, CCP)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANN
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:MED,RDN, CDE, CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 961845
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-6912
Mailing Address - Country:US
Mailing Address - Phone:678-908-3319
Mailing Address - Fax:
Practice Address - Street 1:7562 SUGARCREEK DR
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-3373
Practice Address - Country:US
Practice Address - Phone:678-908-3319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001554133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered