Provider Demographics
NPI:1174244032
Name:GLEASON, LAUREN (RD)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:GLEASON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:810 SCOTT CIR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4717
Mailing Address - Country:US
Mailing Address - Phone:404-436-3363
Mailing Address - Fax:
Practice Address - Street 1:810 SCOTT CIR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4717
Practice Address - Country:US
Practice Address - Phone:770-846-6669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86057838133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered