Healthcare Provider Details

I. General information

NPI: 1972059913
Provider Name (Legal Business Name): SUSAN TYLER WALLACE HARDING M.S., R.D., L.D.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 MANOR RD
CHARLOTTE NC
28209-2247
US

IV. Provider business mailing address

2909 MANOR RD
CHARLOTTE NC
28209-2247
US

V. Phone/Fax

Practice location:
  • Phone: 804-337-8835
  • Fax:
Mailing address:
  • Phone: 804-337-8835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberL004973
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL004973
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: