Healthcare Provider Details

I. General information

NPI: 1144346255
Provider Name (Legal Business Name): SHIRLEY PELLETIER R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 NC HIGHWAY 45 N
PLYMOUTH NC
27962-9232
US

IV. Provider business mailing address

195 GUSTOWN RD
CRESWELL NC
27928-8805
US

V. Phone/Fax

Practice location:
  • Phone: 252-791-3100
  • Fax: 252-793-0129
Mailing address:
  • Phone: 252-797-7517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number920339
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: