MEDICARE: JACQUELYN SHARP WOMBLE MS, RDN, LD, EP-C

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	972	SC
2	133V00000X	Registered Dietitian	L005137	NC

General Provider Information

NPI Number	:	1508140013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYN SHARP WOMBLE MS, RDN, LD, EP-C

Provider Business Mailing Address
First Line	:	8962 KIRKLEY VIEW CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-5715
Country	:	US
Telephone Number	:	843-209-7142
Fax Number	:

Provider Business Practice Location Address
First Line	:	8962 KIRKLEY VIEW CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-5715
Country	:	US
Telephone Number	:	843-209-7142
Fax Number	:

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

Provider Enumeration Date	:	10/03/2011
Last Update Date	:	03/17/2018

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