Healthcare Provider Details

I. General information

NPI: 1194206268
Provider Name (Legal Business Name): PATIENCE WOODARD ERGISH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 07/15/2024
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BLYTHE BLVD STE 500
CHARLOTTE NC
28203-5866
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-373-1813
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL006530
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: