Provider Demographics
NPI:1740539741
Name:GODOLPHIN, FELICIA M (RD,LDN, CNSC)
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:M
Last Name:GODOLPHIN
Suffix:
Gender:F
Credentials:RD,LDN, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3179 SONJA WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7071
Mailing Address - Country:US
Mailing Address - Phone:843-901-5992
Mailing Address - Fax:
Practice Address - Street 1:3179 SONJA WAY
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7071
Practice Address - Country:US
Practice Address - Phone:843-901-5992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1313133NN1002X, 133V00000X, 133VN1006X
TN0000001606133NN1002X, 133V00000X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered