Healthcare Provider Details

I. General information

NPI: 1801683040
Provider Name (Legal Business Name): LYDIA HEDGEPETH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1249 ETTRICK AVE
ROCK HILL SC
29732-2987
US

IV. Provider business mailing address

1249 ETTRICK AVE
ROCK HILL SC
29732-2987
US

V. Phone/Fax

Practice location:
  • Phone: 614-813-3051
  • Fax:
Mailing address:
  • Phone: 614-813-3051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License NumberL008029
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: