Provider Demographics
NPI:1427539469
Name:MAMMES, GRACE ANNE (LDN RD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ANNE
Last Name:MAMMES
Suffix:
Gender:F
Credentials:LDN RD
Other - Prefix:MS
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:BRUENING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LDN, RD
Mailing Address - Street 1:172 WILLIAMSON RD UNIT 5205
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5000
Mailing Address - Country:US
Mailing Address - Phone:704-562-8373
Mailing Address - Fax:704-680-6672
Practice Address - Street 1:8100 OLD MALLARD CREEK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-2238
Practice Address - Country:US
Practice Address - Phone:704-716-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC86049634133V00000X
NCL005564133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered