Provider Demographics
NPI:1699274811
Name:BLALOCK, BETHANY (RDN)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-4030
Mailing Address - Country:US
Mailing Address - Phone:804-852-0851
Mailing Address - Fax:
Practice Address - Street 1:817 VILLAGE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4030
Practice Address - Country:US
Practice Address - Phone:804-852-0851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered