Basic Information
| Provider Information | |||||||||
| NPI: | 1629164355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANNON | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | EDWARDS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD. LD. MSA, DMIN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRANNON | ||||||||
| OtherFirstName: | AUDREY | ||||||||
| OtherMiddleName: | EDWARDS | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DOCTORATE MINISTRY | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 FREEDOM WAY | ||||||||
| Address2: | 296 U | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067330188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 FREEDOM WAY | ||||||||
| Address2: | 296 U | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067330188 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/01/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | LD002235 | 01 | GA | GA LICENSURE | OTHER | 725487 | 01 | GA | CDR, RD REGISTRATION NUM | OTHER |