Provider Demographics
NPI:1972928307
Name:GILLIAM, COURTNEY (MS, RD, LDN, CSSD)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:MS, RD, LDN, CSSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 BURNT MILL DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2576
Mailing Address - Country:US
Mailing Address - Phone:910-790-9500
Mailing Address - Fax:
Practice Address - Street 1:3240 BURNT MILL DR
Practice Address - Street 2:SUITE 1
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2576
Practice Address - Country:US
Practice Address - Phone:910-790-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-21
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1031699133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered