Basic Information
| Provider Information | |||||||||
| NPI: | 1699259168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIATT | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | MS, RD, LDN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SORVILLO | ||||||||
| OtherFirstName: | ANDREA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043167740 | ||||||||
| FaxNumber: | 7043167745 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450 MATTHEWS TOWNSHIP PKWY STE 110 | ||||||||
| Address2: | |||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281052388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043167760 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2018 | ||||||||
| LastUpdateDate: | 05/31/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | L004248 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.