Healthcare Provider Details

I. General information

NPI: 1356779375
Provider Name (Legal Business Name): JOANNE GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2013
Last Update Date: 10/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3475 ERWIN ROAD
DURHAM NC
27705-2664
US

IV. Provider business mailing address

PO BOX 751274
CHARLOTTE NC
28275-1274
US

V. Phone/Fax

Practice location:
  • Phone: 919-660-6826
  • Fax:
Mailing address:
  • Phone: 919-620-4491
  • Fax: 800-782-6945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL004224
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: