Provider Demographics
NPI:1710445796
Name:STEPHENSON, PRESTON WAYNE (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:WAYNE
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 604050
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-4050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 OAK BRANCH DR STE C
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-2444
Practice Address - Country:US
Practice Address - Phone:336-579-2312
Practice Address - Fax:336-579-2365
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-08
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLOO5646133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered