Healthcare Provider Details

I. General information

NPI: 1578819041
Provider Name (Legal Business Name): NICOLE MARIE MATALA MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS NICOLE MARIE ROJENCHES

II. Dates (important events)

Enumeration Date: 08/01/2012
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S SALEM ST
APEX NC
27502-1825
US

IV. Provider business mailing address

2620 NEW BERN AVE
RALEIGH NC
27610-1821
US

V. Phone/Fax

Practice location:
  • Phone: 919-362-5201
  • Fax:
Mailing address:
  • Phone: 919-255-6721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL003997
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: