Provider Demographics
NPI:1134224660
Name:SOUTHERN, ELLEN SUSANNAH (RD,LDN)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:SUSANNAH
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:RD,LDN
Other - Prefix:MRS
Other - First Name:ELLEN
Other - Middle Name:SOUTHERN
Other - Last Name:PRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:211 FRIDAY CENTER DRIVE, HEDRICK BUILDING
Mailing Address - Street 2:SUITE 2091, ROOM 2102
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-9499
Mailing Address - Country:US
Mailing Address - Phone:984-974-1186
Mailing Address - Fax:984-974-1311
Practice Address - Street 1:590 MANNING DR
Practice Address - Street 2:ROOM 103
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-6119
Practice Address - Country:US
Practice Address - Phone:919-966-6875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002429133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
2994383Medicare ID - Type UnspecifiedPERFORMING PROV NUMBER