Basic Information
| Provider Information | |||||||||
| NPI: | 1487800314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAIRCLOTH | ||||||||
| FirstName: | CRISTIE | ||||||||
| MiddleName: | WELLS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C, RD, LDN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WELLS | ||||||||
| OtherFirstName: | CRISTIE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10130 PERIMETER PKWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282162447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888497379 | ||||||||
| FaxNumber: | 8558577333 | ||||||||
| Practice Location | |||||||||
| Address1: | 10130 PERIMETER PKWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282162447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888497379 | ||||||||
| FaxNumber: | 8558577333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2008 | ||||||||
| LastUpdateDate: | 02/10/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | L002256 | NC | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 363A00000X | 0010-1457 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 133V00000X | 915208 | NC | N | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 8101417 | 05 | NC | MEDICAID | 17998 | 01 | NC | BCBS NC | OTHER |