=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336357235
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH BARRETT THOMPSON MPH, RD, LDN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 09/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1209 RIDGE RD
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27607-6852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-946-6774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 PALMETTO ST
-----------------------------------------------------
City | NEW SMYRNA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32168-7322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-424-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | L001923
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------