Basic Information
| Provider Information | |||||||||
| NPI: | 1154053981 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUNAGAN | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | AMANDA | ||||||||
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| Credential: | RDN, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 604050 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282604050 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 730 HIGHLAND OAKS DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271037154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366467323 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2022 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LDN0000003336 | TN | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | L007008 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.