Provider Demographics
NPI:1447834965
Name:RYAN, SHIELA COCHRAN (RD)
Entity type:Individual
Prefix:
First Name:SHIELA
Middle Name:COCHRAN
Last Name:RYAN
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 1:90 HANNAH WAY
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-8549
Mailing Address - Country:US
Mailing Address - Phone:678-326-2761
Mailing Address - Fax:
Practice Address - Street 1:1136 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3618
Practice Address - Country:US
Practice Address - Phone:404-466-6303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD005188133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALD005188OtherDIETITIANS LICENSE