Provider Demographics
NPI:1487290995
Name:WILSON, CHARLENE (RDN, LD)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4553 FAIRECROFT TER
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4066
Mailing Address - Country:US
Mailing Address - Phone:770-231-9264
Mailing Address - Fax:
Practice Address - Street 1:1325 SATELLITE BLVD NW STE 103
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4697
Practice Address - Country:US
Practice Address - Phone:770-231-9264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD005433133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered