Provider Demographics
NPI:1053166298
Name:LODGE, STEPHANIE
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:LODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 CHASTAIN DR NE # 2417
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4157
Mailing Address - Country:US
Mailing Address - Phone:610-864-4344
Mailing Address - Fax:
Practice Address - Street 1:2417 CHASTAIN DR NE # 2417
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4157
Practice Address - Country:US
Practice Address - Phone:610-864-4344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education