Provider Demographics
NPI:1790246304
Name:BURKETT, CHRISTOPHER (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:BURKETT
Suffix:
Gender:M
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 STEELE LOOP
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-6207
Mailing Address - Country:US
Mailing Address - Phone:410-430-4102
Mailing Address - Fax:
Practice Address - Street 1:STONE BAY BASE RR136
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:28445
Practice Address - Country:US
Practice Address - Phone:410-430-4102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86043939133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86043939OtherCOMISSION ON DIETETICS REGISTRATION