MEDICARE: BRAEDYN WESLEY MALLARD RDN, LDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	L005687	NC

General Provider Information

NPI Number	:	1245845122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRAEDYN WESLEY MALLARD RDN, LDN

Provider Business Mailing Address
First Line	:	2905 UNIVERSITY DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27707-3854
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2905 UNIVERSITY DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27707-3854
Country	:	US
Telephone Number	:	919-274-6166
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2020
Last Update Date	:	09/09/2020

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