Basic Information
| Provider Information | |||||||||
| NPI: | 1922496173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKINS | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | BOLT | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23 SUNNYBROOK RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192346435 | ||||||||
| FaxNumber: | 9192310314 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 SUNNYBROOK RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192346435 | ||||||||
| FaxNumber: | 9192310314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2014 | ||||||||
| LastUpdateDate: | 12/22/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1004X | 962233 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric | 133VN1004X | L002674 | NC | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric |
No ID Information.