Provider Demographics
NPI:1124811864
Name:PORTER, SARA BRADLEY (MS RD LD)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:BRADLEY
Last Name:PORTER
Suffix:
Gender:F
Credentials:MS RD LD
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:BRADLEY
Other - Last Name:SHECKELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2736 LAUREL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-2934
Mailing Address - Country:US
Mailing Address - Phone:251-554-0242
Mailing Address - Fax:
Practice Address - Street 1:2736 LAUREL RIDGE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2934
Practice Address - Country:US
Practice Address - Phone:251-554-0242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-26
Last Update Date:2025-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD007123133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered