Healthcare Provider Details

I. General information

NPI: 1780895136
Provider Name (Legal Business Name): SHERRIE FENNELL EDWARDS RD.,LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LANELY AVE. SEYMOUR JOHNSON AFB
GOLSBORO NC
27534
US

IV. Provider business mailing address

1804 DOGWOOD ST
GOLDSBORO NC
27534-2320
US

V. Phone/Fax

Practice location:
  • Phone: 919-722-0407
  • Fax:
Mailing address:
  • Phone: 919-739-5081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number714599
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: