Provider Demographics
NPI:1255792602
Name:WOODSIDE, COURTNEY LOCKLEAR (RD LDN)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LOCKLEAR
Last Name:WOODSIDE
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:ROSE
Other - Last Name:LOCKLEAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LDN
Mailing Address - Street 1:17 PUMPKIN PL
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-6097
Mailing Address - Country:US
Mailing Address - Phone:910-638-5266
Mailing Address - Fax:
Practice Address - Street 1:17 PUMPKIN PL
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-6097
Practice Address - Country:US
Practice Address - Phone:910-638-5266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-13
Last Update Date:2016-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004388133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered