Provider Demographics
NPI:1740202936
Name:WEBER, NANCY JO (MBA, RD, CDE, CSR, L)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:JO
Last Name:WEBER
Suffix:
Gender:F
Credentials:MBA, RD, CDE, CSR, L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 AUBURN LANE
Mailing Address - Street 2:24H
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575
Mailing Address - Country:US
Mailing Address - Phone:843-839-9088
Mailing Address - Fax:888-909-5897
Practice Address - Street 1:11945 GRANDHAVEN DRIVE
Practice Address - Street 2:SUITE G
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576
Practice Address - Country:US
Practice Address - Phone:843-839-9088
Practice Address - Fax:888-909-5897
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001180133VN1005X
SCR605535133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC179OtherSC LICENSE
P78017Medicare UPIN
GA71BBBPGMedicare ID - Type Unspecified
SC179OtherSC LICENSE