Provider Demographics
NPI:1578521035
Name:GREGORY, MARY SUSAN (MS, RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:SUSAN
Last Name:GREGORY
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 CEDAR KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-7792
Mailing Address - Country:US
Mailing Address - Phone:336-789-3016
Mailing Address - Fax:
Practice Address - Street 1:118 HAMBY RD
Practice Address - Street 2:
Practice Address - City:DOBSON
Practice Address - State:NC
Practice Address - Zip Code:27017-8471
Practice Address - Country:US
Practice Address - Phone:336-401-8455
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL000989133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404481Medicaid
NCP71299Medicare UPIN
NC3404481Medicaid