Provider Demographics
NPI:1487800314
Name:FAIRCLOTH, CRISTIE WELLS (PA-C, RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:CRISTIE
Middle Name:WELLS
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:PA-C, RD, LDN
Other - Prefix:MISS
Other - First Name:CRISTIE
Other - Middle Name:MARIE
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10130 PERIMETER PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-2447
Mailing Address - Country:US
Mailing Address - Phone:888-849-7379
Mailing Address - Fax:855-857-7333
Practice Address - Street 1:10130 PERIMETER PKWY
Practice Address - Street 2:STE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-2447
Practice Address - Country:US
Practice Address - Phone:888-849-7379
Practice Address - Fax:855-857-7333
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002256133V00000X
NC0010-1457363A00000X
NC915208133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101417Medicaid
NC17998OtherBCBS NC
NC8101417Medicaid