Healthcare Provider Details

I. General information

NPI: 1487099511
Provider Name (Legal Business Name): MRS. TERAH NICOLE STARBUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 E 4TH ST
CHARLOTTE NC
28202-2434
US

IV. Provider business mailing address

1700 EMERYWOOD DR
CHARLOTTE NC
28210-4142
US

V. Phone/Fax

Practice location:
  • Phone: 704-380-4655
  • Fax:
Mailing address:
  • Phone: 336-692-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL003814
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: