Basic Information
| Provider Information | |||||||||
| NPI: | 1790888519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FELLOWS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | A | ||||||||
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| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 N WINSTEAD AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278048467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529340200 | ||||||||
| FaxNumber: | 2524430096 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 N WINSTEAD AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278048467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529370200 | ||||||||
| FaxNumber: | 2524430096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 08/27/2007 | ||||||||
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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 | L002536 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | P00165586 | 01 | NC | RAILROAD MEDICARE | OTHER |