Provider Demographics
NPI:1316057862
Name:GRESHAM, MARY ETTA JAMES (RDLD)
Entity type:Individual
Prefix:
First Name:MARY ETTA
Middle Name:JAMES
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ETTA
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDLD
Mailing Address - Street 1:5330 CAYUGA CT
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-1106
Mailing Address - Country:US
Mailing Address - Phone:404-578-6525
Mailing Address - Fax:
Practice Address - Street 1:5330 CAYUGA CT
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-1106
Practice Address - Country:US
Practice Address - Phone:404-578-6525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000377133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBBTTMedicare PIN