Basic Information
| Provider Information | |||||||||
| NPI: | 1366639718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAUFMAN | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103413300 | ||||||||
| FaxNumber: | 9102518824 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 PHYSICIANS DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103413300 | ||||||||
| FaxNumber: | 9102518824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 08/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1006X | L000491 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic |
ID Information
| ID | Type | State | Issuer | Description | 51857 | 01 | NC | BLUE CROSS BLUE SHIELD NC | OTHER | L000491 | 01 | NC | NC LICENSE | OTHER |