Healthcare Provider Details

I. General information

NPI: 1760552947
Provider Name (Legal Business Name): BEVERLY G GARDNER LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 CRUTCHFIELD ST
DURHAM NC
27704-2726
US

IV. Provider business mailing address

PO BOX 63362
CHARLOTTE NC
28263-3362
US

V. Phone/Fax

Practice location:
  • Phone: 919-470-6516
  • Fax:
Mailing address:
  • Phone: 919-620-4918
  • Fax: 919-620-4921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberL000559
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberL000559
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL000559
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: