Basic Information
| Provider Information | |||||||||
| NPI: | 1568108413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARRETT | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | MRS. | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | DANIEL | ||||||||
| OtherFirstName: | GRACE | ||||||||
| OtherMiddleName: | FOSTER | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3112 ALTAMAHAW UNION RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272177310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365147601 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 E WENDOVER AVE STE 311 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362726161 | ||||||||
| FaxNumber: | 3362302150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2022 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | L006876 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.