Provider Demographics
NPI:1679188064
Name:MATTERN, TARYN (RDN, LDN)
Entity type:Individual
Prefix:MRS
First Name:TARYN
Middle Name:
Last Name:MATTERN
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 SELWYN AVE
Mailing Address - Street 2:SUITE 130, BOX 651
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209
Mailing Address - Country:US
Mailing Address - Phone:704-709-5021
Mailing Address - Fax:
Practice Address - Street 1:2820 SELWYN AVE
Practice Address - Street 2:SUITE 130, BX 651
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2820
Practice Address - Country:US
Practice Address - Phone:704-709-5021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2021-05-06
Deactivation Date:2021-03-30
Deactivation Code:
Reactivation Date:2021-05-06
Provider Licenses
StateLicense IDTaxonomies
NCL005470133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered