MEDICARE: MRS. CRISTIE WELLS FAIRCLOTH PA-C, 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
1	133V00000X	Registered Dietitian	L002256	NC
2	363A00000X	Physician Assistant	0010-1457	NC
3	133V00000X	Registered Dietitian	915208	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	17998	OTHER	NC	BCBS NC

General Provider Information

NPI Number	:	1487800314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRISTIE WELLS FAIRCLOTH PA-C, RD, LDN

Provider Business Mailing Address
First Line	:	10130 PERIMETER PKWY
Second Line	:	STE 200
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-2447
Country	:	US
Telephone Number	:	888-849-7379
Fax Number	:	855-857-7333

Provider Business Practice Location Address
First Line	:	10130 PERIMETER PKWY
Second Line	:	STE 200
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-2447
Country	:	US
Telephone Number	:	888-849-7379
Fax Number	:	855-857-7333

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2008
Last Update Date	:	02/10/2017

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