Provider Demographics
NPI:1821358326
Name:GORDON, REGINA ANN (RD, LDN)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:ANN
Last Name:GORDON
Suffix:
Gender:F
Credentials:RD, 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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-718-5746
Mailing Address - Fax:336-718-6190
Practice Address - Street 1:1901 S HAWTHORNE RD
Practice Address - Street 2:SUITE 360
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3921
Practice Address - Country:US
Practice Address - Phone:336-718-5746
Practice Address - Fax:336-718-6190
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001243133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ40400AMedicare PIN