Basic Information
| Provider Information | |||||||||
| NPI: | 1346869617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WU | ||||||||
| FirstName: | TIFFANY | ||||||||
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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: | 3366467787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2020 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | L006131 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.