Provider Demographics
NPI:1821184300
Name:WALLERICH, CYNTHIA SUE (MS, RD, LD)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:SUE
Last Name:WALLERICH
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 CARLTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-3505
Mailing Address - Country:US
Mailing Address - Phone:706-733-0188
Mailing Address - Fax:
Practice Address - Street 1:ONE FREEDOM WAY
Practice Address - Street 2:MEDICAL CENTER ROUTING SYMBOL 295
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904
Practice Address - Country:US
Practice Address - Phone:706-733-0188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001616133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered