Provider Demographics
NPI:1659911626
Name:WILKES, SANDRA RUAN (RD, CSR)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:RUAN
Last Name:WILKES
Suffix:
Gender:F
Credentials:RD, CSR
Other - Prefix:MRS
Other - First Name:SANDRA
Other - Middle Name:LIAN
Other - Last Name:RUAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CSR
Mailing Address - Street 1:1013 TRINITY DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-8056
Mailing Address - Country:US
Mailing Address - Phone:919-809-4890
Mailing Address - Fax:
Practice Address - Street 1:1013 TRINITY DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-8056
Practice Address - Country:US
Practice Address - Phone:919-809-4890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC86024294133V00000X, 133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered