Healthcare Provider Details

I. General information

NPI: 1902159130
Provider Name (Legal Business Name): KRISTEN ELLEDGE ANDREWS RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 WESTGATE CENTER DR STE 110
WINSTON SALEM NC
27103-3104
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-277-1660
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL004063
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: