Healthcare Provider Details

I. General information

NPI: 1679265797
Provider Name (Legal Business Name): SELF WINS FUNCTIONAL NUTRITION CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 07/31/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 EDEN WAY N STE E158
CHESAPEAKE VA
23320-2798
US

IV. Provider business mailing address

732 EDEN WAY N STE E158
CHESAPEAKE VA
23320-2798
US

V. Phone/Fax

Practice location:
  • Phone: 757-714-6500
  • Fax:
Mailing address:
  • Phone: 757-714-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: SHARON HARPER
Title or Position: OWNER
Credential: HHP
Phone: 757-714-6500