Provider Demographics
NPI:1306395652
Name:SYN, MIA (MS, RD)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:SYN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 WENTWORTH ST
Mailing Address - Street 2:APARTMENT 4A
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-1762
Mailing Address - Country:US
Mailing Address - Phone:408-204-7882
Mailing Address - Fax:
Practice Address - Street 1:124 WENTWORTH ST
Practice Address - Street 2:APARTMENT 4A
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1762
Practice Address - Country:US
Practice Address - Phone:408-204-7882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1561133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered