Provider Demographics
NPI:1215819362
Name:GORDON, OLIVIA KATELYN (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:KATELYN
Last Name:GORDON
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:KATEY
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:118 BROOKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30116-4935
Mailing Address - Country:US
Mailing Address - Phone:678-446-4952
Mailing Address - Fax:
Practice Address - Street 1:118 BROOKSTONE DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30116-4935
Practice Address - Country:US
Practice Address - Phone:678-446-4952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-21
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD007297133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered