Provider Demographics
NPI:1568282747
Name:BOURGEOIS, MADELYN BURK
Entity type:Individual
Prefix:
First Name:MADELYN
Middle Name:BURK
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BLYTHE BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5863
Mailing Address - Country:US
Mailing Address - Phone:704-373-1813
Mailing Address - Fax:
Practice Address - Street 1:1001 BLYTHE BLVD STE 500
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5863
Practice Address - Country:US
Practice Address - Phone:704-373-1813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL008240133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered