Provider Demographics
NPI:1255944716
Name:CHAFFIN, CORETTA QUEEN
Entity type:Individual
Prefix:
First Name:CORETTA
Middle Name:QUEEN
Last Name:CHAFFIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CORETTA
Other - Middle Name:QUEEN
Other - Last Name:CLEMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3717 OLD WAGON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1994
Mailing Address - Country:US
Mailing Address - Phone:704-562-5331
Mailing Address - Fax:
Practice Address - Street 1:7940 WILLIAMS POND LN STE 150
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-8409
Practice Address - Country:US
Practice Address - Phone:704-247-8355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC810909133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered