Healthcare Provider Details

I. General information

NPI: 1730604513
Provider Name (Legal Business Name): EMILY KRUEGER LYBBERT RDN, MS, CSOWM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5045 WALDEN RIDGE DR
WINSTON SALEM NC
27127-6811
US

IV. Provider business mailing address

5045 WALDEN RIDGE DR
WINSTON SALEM NC
27127-6811
US

V. Phone/Fax

Practice location:
  • Phone: 910-723-4559
  • Fax:
Mailing address:
  • Phone: 910-723-4559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL006221
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number9893745-4901
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: