Healthcare Provider Details

I. General information

NPI: 1407747173
Provider Name (Legal Business Name): MAKAYLA MITCHELL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2025
Last Update Date: 07/11/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 N ELM ST
GREENSBORO NC
27401-6309
US

IV. Provider business mailing address

1121 N CHURCH ST ATTN: CLINICAL DIETITIANS DEPARTMENT OFFICE #2C304
GREENSBORO NC
27401-1007
US

V. Phone/Fax

Practice location:
  • Phone: 336-271-3331
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL007013
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: