Provider Demographics
NPI:1619839107
Name:BRYANT, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:BRYANT
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 1:6957 ROSWELL RD APT I
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-2364
Mailing Address - Country:US
Mailing Address - Phone:910-833-4539
Mailing Address - Fax:
Practice Address - Street 1:6957 ROSWELL RD APT I
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-2364
Practice Address - Country:US
Practice Address - Phone:910-833-4539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-02
Last Update Date:2025-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD007418133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered