Healthcare Provider Details

I. General information

NPI: 1306625983
Provider Name (Legal Business Name): STEPHANIE ALLEN CARPENTER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 HIGHLAND OAKS DR STE 201
WINSTON SALEM NC
27103-7108
US

IV. Provider business mailing address

142 CORAVAN CT
WINSTON SALEM NC
27106-4785
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-2425
  • Fax: 336-768-4915
Mailing address:
  • Phone: 662-809-7833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberL004222
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: