Healthcare Provider Details

I. General information

NPI: 1124711650
Provider Name (Legal Business Name): ASIA ISADORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 CARRINGTON PL UNIT 1
FAYETTEVILLE NC
28314-0994
US

IV. Provider business mailing address

204 CARRINGTON PL UNIT 1
FAYETTEVILLE NC
28314-0994
US

V. Phone/Fax

Practice location:
  • Phone: 843-714-0397
  • Fax:
Mailing address:
  • Phone: 843-714-0397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: