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General NPI Number Information
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NPI Number | 1336872704
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Entity Type | Individual
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Provider Name | KRISTA BIRD PANCAKE RD
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Gender | Female
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Dates
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Enumeration Date | 07/05/2022
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Last Update Date | 12/11/2024
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Provider Practice Location Address
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Address Line | 1001 BLYTHE BLVD STE 200F
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City | CHARLOTTE
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State | NC
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Zip | 28203-5866
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Country | US
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Telephone | 704-381-6850
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Fax |
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Provider Business Mailing Address
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Address Line | 6500 DEERMONT CT
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City | CHARLOTTE
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State | NC
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Zip | 28211-6202
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133VN1004X
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Taxonomy Name | Pediatric Nutrition Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 86152091
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | L006185
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License Number State | NC
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