Basic Information
| Provider Information | |||||||||
| NPI: | 1669646048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNERMAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | R.D., LDN, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7300 RAEFORD RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283040807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104882120 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7300 S RAEFORD RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283046162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104756296 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2008 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | L000337 | NC | N | Dietary & Nutritional Service Providers | Nutritionist | 133V00000X | L000337 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.