Healthcare Provider Details

I. General information

NPI: 1710077391
Provider Name (Legal Business Name): JUDY ELLEN FISCHER RD, LDN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 E CHARLES ST STE D
MATTHEWS NC
28105-4911
US

IV. Provider business mailing address

12113 LANDEN DRIVE
CHARLOTTE NC
28277
US

V. Phone/Fax

Practice location:
  • Phone: 704-299-5501
  • Fax:
Mailing address:
  • Phone: 704-299-5591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL001156
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: