MEDICARE: HEATHER RENEE CUPP R.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian
2	133V00000X	Registered Dietitian	L006978	NC

General Provider Information

NPI Number	:	1932185378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER RENEE CUPP R.D.

Provider Business Mailing Address
First Line	:	PO BOX 602195
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-2195
Country	:	US
Telephone Number	:	877-498-4490
Fax Number	:

Provider Business Practice Location Address
First Line	:	2930 FORESTVILLE RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-8774
Country	:	US
Telephone Number	:	919-235-6550
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	10/23/2023

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