Healthcare Provider Details

I. General information

NPI: 1508379595
Provider Name (Legal Business Name): SONDRA TACKETT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 11/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19607 W CATAWBA AVE
CORNELIUS NC
28031-4002
US

IV. Provider business mailing address

172 WILLIAMSON RD UNIT 5205
MOORESVILLE NC
28117-5000
US

V. Phone/Fax

Practice location:
  • Phone: 704-895-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86027981
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: