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General NPI Number Information
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NPI Number | 1487800314
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Entity Type | Individual
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Provider Name | CRISTIE WELLS FAIRCLOTH PA-C, RD, LDN
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Gender | Female
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Dates
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Enumeration Date | 08/12/2008
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Last Update Date | 02/10/2017
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Provider Practice Location Address
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Address Line | 10130 PERIMETER PKWY STE 200
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City | CHARLOTTE
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State | NC
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Zip | 28216-2447
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Country | US
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Telephone | 888-849-7379
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Fax | 855-857-7333
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Provider Business Mailing Address
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Address Line | 10130 PERIMETER PKWY STE 200
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City | CHARLOTTE
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State | NC
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Zip | 28216-2447
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Country | US
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Telephone | 888-849-7379
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Fax | 855-857-7333
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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 | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | L002256
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0010-1457
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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 | 915208
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License Number State | NC
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