Provider Demographics
NPI:1427307297
Name:DIETRICH, TINA SCHMIDT (MS, RD, LDN)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:SCHMIDT
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9414 PENSHURST TRCE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-7713
Mailing Address - Country:US
Mailing Address - Phone:704-747-9457
Mailing Address - Fax:
Practice Address - Street 1:9414 PENSHURST TRCE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-7713
Practice Address - Country:US
Practice Address - Phone:704-747-9457
Practice Address - Fax:980-236-7656
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC833664133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC833664OtherREGISTERED DIETIAN
NCL001240OtherLICENSED DIETITIAN