Provider Demographics
NPI:1053098988
Name:YOUNG, ELAINE MARIE (RD)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:MARIE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:MARIE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1049 POWERS FERRY RD SE APT 101
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-5818
Mailing Address - Country:US
Mailing Address - Phone:769-223-9118
Mailing Address - Fax:
Practice Address - Street 1:1049 POWERS FERRY RD SE APT 101
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5818
Practice Address - Country:US
Practice Address - Phone:769-223-9118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD005884133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered