Provider Demographics
NPI:1568883759
Name:FRUIT OF THE SPIRIT NUTRITION AND WELLNESS, LLC
Entity Type:Organization
Organization Name:FRUIT OF THE SPIRIT NUTRITION AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN, NUTRITIONIST
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LDN
Authorized Official - Phone:704-785-1043
Mailing Address - Street 1:5710 N OAKMONT ST
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28081-6418
Mailing Address - Country:US
Mailing Address - Phone:704-785-1043
Mailing Address - Fax:
Practice Address - Street 1:121 GREENWICH RD
Practice Address - Street 2:SUITE 215
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2355
Practice Address - Country:US
Practice Address - Phone:704-785-1043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-15
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL00325133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1336307479OtherINDIVIDUAL NPI NUMBER