Provider Demographics
NPI:1538332663
Name:WHITESIDE, MARY LAUREN (RD, CSP, LD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LAUREN
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:RD, CSP, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 WATERS AVE
Mailing Address - Street 2:P.O. BOX 23089
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-9473
Mailing Address - Fax:843-350-9557
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:FOOD & NUTRITION SERVICES
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-9473
Practice Address - Fax:843-350-9557
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC160133VN1004X
GA003750133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003124845AMedicaid