1386345676 NPI number — CHRISTINE LAURA CANTERBERRY MS, RD, LD.

Table of content: CHRISTINE LAURA CANTERBERRY MS, RD, LD. (NPI 1386345676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386345676 NPI number — CHRISTINE LAURA CANTERBERRY MS, RD, LD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANTERBERRY
Provider First Name:
CHRISTINE
Provider Middle Name:
LAURA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, RD, LD.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386345676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
816 GLENDALE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25303-2519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-395-5530
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1206 VIRGINIA ST E STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25301-2937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-395-5530
Provider Business Practice Location Address Fax Number:
681-245-6369
Provider Enumeration Date:
03/14/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  1085 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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