Provider Demographics
NPI:1992349443
Name:RICHARDSON, ALLISON RENAE (RDN, LD)
Entity type:Individual
Prefix:MRS
First Name:ALLISON
Middle Name:RENAE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:897 PECAN TREE LN
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-7010
Mailing Address - Country:US
Mailing Address - Phone:515-975-8722
Mailing Address - Fax:
Practice Address - Street 1:5970 FAIRVIEW RD STE 420
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3167
Practice Address - Country:US
Practice Address - Phone:980-701-4190
Practice Address - Fax:980-701-4194
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005977133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCL005977OtherNORTH CAROLINA DIETITIAN LICENSE
SC1793OtherSOUTH CAROLINA DIETITIAN LICENSE