Healthcare Provider Details

I. General information

NPI: 1871950121
Provider Name (Legal Business Name): ANGELA MAYNOR RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2016
Last Update Date: 01/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MANNING DR
CHAPEL HILL NC
27514-4220
US

IV. Provider business mailing address

101 THOMAS LN APT A2
CARRBORO NC
27510-1366
US

V. Phone/Fax

Practice location:
  • Phone: 984-974-4790
  • Fax: 984-974-3217
Mailing address:
  • Phone: 919-632-0554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberL000916
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: