Healthcare Provider Details

I. General information

NPI: 1194237511
Provider Name (Legal Business Name): ANGELA DENISE CORDER MS, RDN, CSP, FAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2017
Last Update Date: 10/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 W MAIN ST
LEXINGTON SC
29072-2661
US

IV. Provider business mailing address

501 LAUREL CRK
ANDERSON SC
29621-1049
US

V. Phone/Fax

Practice location:
  • Phone: 888-765-3438
  • Fax: 855-222-2815
Mailing address:
  • Phone: 864-940-5887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberL004779
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1431
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD003427
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1431
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL004779
License Number StateNC
# 6
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number57
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: