Provider Demographics
NPI:1942417019
Name:GRIDLEY, TONDA (RD)
Entity type:Individual
Prefix:
First Name:TONDA
Middle Name:
Last Name:GRIDLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 COPPERFIELD BLVD NE
Practice Address - Street 2:STE 102
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2441
Practice Address - Country:US
Practice Address - Phone:704-786-6521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001311133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1942417019Medicaid
NC1942417019Medicaid
NC2991414Medicare PIN