Healthcare Provider Details

I. General information

NPI: 1922369222
Provider Name (Legal Business Name): RAQUEL DURBAN MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 E 7TH ST UNIT A
CHARLOTTE NC
28204-4398
US

IV. Provider business mailing address

2600 E 7TH ST UNIT A
CHARLOTTE NC
28204-4398
US

V. Phone/Fax

Practice location:
  • Phone: 704-372-7900
  • Fax:
Mailing address:
  • Phone: 704-372-7900
  • Fax: 704-376-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1075612
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: