Healthcare Provider Details

I. General information

NPI: 1710633367
Provider Name (Legal Business Name): ABIGAIL MOON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ABIGAIL ROLLISON RD

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 06/07/2025
Certification Date: 06/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 DOUGLAS ST STE 500
DURHAM NC
27705-6616
US

IV. Provider business mailing address

PO BOX 13289
DURHAM NC
27709-3289
US

V. Phone/Fax

Practice location:
  • Phone: 919-908-9730
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL006635
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: