Provider Demographics
NPI:1972059913
Name:HARDING, SUSAN TYLER WALLACE (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:TYLER WALLACE
Last Name:HARDING
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 1:2909 MANOR RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2247
Mailing Address - Country:US
Mailing Address - Phone:804-337-8835
Mailing Address - Fax:
Practice Address - Street 1:2909 MANOR RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2247
Practice Address - Country:US
Practice Address - Phone:804-337-8835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004973133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education