Provider Demographics
NPI:1841915253
Name:ANNAMALAI, PRAKASAM (RDN)
Entity type:Individual
Prefix:
First Name:PRAKASAM
Middle Name:
Last Name:ANNAMALAI
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10919 BENNETT DR
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-7657
Mailing Address - Country:US
Mailing Address - Phone:843-452-0281
Mailing Address - Fax:
Practice Address - Street 1:10919 BENNETT DR
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-7657
Practice Address - Country:US
Practice Address - Phone:843-452-0281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
SC2389133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered