Provider Demographics
NPI:1104226265
Name:KING, DEBRA CANNON (MS, RD, LD, CDE)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:CANNON
Last Name:KING
Suffix:
Gender:F
Credentials:MS, RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 WICKERSHAM AVE
Mailing Address - Street 2:
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905-6814
Mailing Address - Country:US
Mailing Address - Phone:913-219-5355
Mailing Address - Fax:
Practice Address - Street 1:7950 MARTIN LOOP
Practice Address - Street 2:MARTIN ARMY COMMUNITY HOSPITAL
Practice Address - City:FT. BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5637
Practice Address - Country:US
Practice Address - Phone:706-544-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004251133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered