Healthcare Provider Details

I. General information

NPI: 1265607147
Provider Name (Legal Business Name): JENNIFER F GREENLY MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 CHARLOIS BLVD
WINSTON SALEM NC
27103-1522
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-5470
  • Fax: 336-499-5428
Mailing address:
  • Phone: 704-384-7840
  • Fax: 704-384-7830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL001762
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: