Provider Demographics
NPI:1174874598
Name:POE, CORDELIA OLYMPIA (LD)
Entity type:Individual
Prefix:
First Name:CORDELIA
Middle Name:OLYMPIA
Last Name:POE
Suffix:
Gender:F
Credentials: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 1827
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31059-1827
Mailing Address - Country:US
Mailing Address - Phone:478-445-4817
Mailing Address - Fax:
Practice Address - Street 1:131 N JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-5513
Practice Address - Country:US
Practice Address - Phone:478-445-4817
Practice Address - Fax:478-445-4963
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000128133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered