Provider Demographics
NPI:1316161474
Name:SOSA, WIDALYS (RD,LD)
Entity type:Individual
Prefix:
First Name:WIDALYS
Middle Name:
Last Name:SOSA
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 342
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30237-0342
Mailing Address - Country:US
Mailing Address - Phone:770-473-6075
Mailing Address - Fax:
Practice Address - Street 1:1920 JOHN WESLEY AVE
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30337-3606
Practice Address - Country:US
Practice Address - Phone:404-765-4168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002227133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered