Healthcare Provider Details

I. General information

NPI: 1295047207
Provider Name (Legal Business Name): STEPHANIE GAYLES MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 07/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 RAMSEY ST
FAYETTEVILLE NC
28301-4401
US

IV. Provider business mailing address

202 E 13TH ST
LUMBERTON NC
28358-4729
US

V. Phone/Fax

Practice location:
  • Phone: 910-433-3764
  • Fax: 910-433-3661
Mailing address:
  • Phone: 910-736-7619
  • Fax: 910-433-3661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number896950
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: