Provider Demographics
NPI:1750967535
Name:RUDISILL, DYLAN SHANE (RD)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:SHANE
Last Name:RUDISILL
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-4303
Mailing Address - Country:US
Mailing Address - Phone:800-905-3261
Mailing Address - Fax:
Practice Address - Street 1:500 PINEVIEW DR STE 205
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-3814
Practice Address - Country:US
Practice Address - Phone:336-329-3295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86074420133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered