Healthcare Provider Details

I. General information

NPI: 1710839915
Provider Name (Legal Business Name): MATTALYNE ANN PALL RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 SAM NEWELL RD STE 204
MATTHEWS NC
28105-7594
US

IV. Provider business mailing address

PO BOX 604050
CHARLOTTE NC
28260-4050
US

V. Phone/Fax

Practice location:
  • Phone: 980-202-6643
  • Fax: 980-246-9482
Mailing address:
  • Phone: 980-202-6643
  • Fax: 980-246-9482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL010178
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: