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NPI Code Detail

MEDICARE: MS. ELLEN SUSANNAH SOUTHERN RD,LDN

MEDICARE: MS. ELLEN SUSANNAH SOUTHERN RD,LDN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered DietitianL002429NC

General Provider Information

NPI Number : 1134224660
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. ELLEN SUSANNAH SOUTHERN RD,LDN
Provider Business Mailing Address
First Line : 211 FRIDAY CENTER DRIVE, HEDRICK BUILDING
Second Line : SUITE 2091, ROOM 2102
City : CHAPEL HILL
State : NC
Zip : 27517-9499
Country : US
Telephone Number : 984-974-1186
Fax Number : 984-974-1311
Provider Business Practice Location Address
First Line : 590 MANNING DR
Second Line : ROOM 103
City : CHAPEL HILL
State : NC
Zip : 27599-6119
Country : US
Telephone Number : 919-966-6875
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/13/2006
Last Update Date : 11/04/2014

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