Healthcare Provider Details

I. General information

NPI: 1043824907
Provider Name (Legal Business Name): MRS. MARIA NARISA TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA NARISA RIEGO RD, LDN

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 CRUTCHFIELD ST
DURHAM NC
27704-2726
US

IV. Provider business mailing address

5 WHITE WILLOW CT
DURHAM NC
27703-9469
US

V. Phone/Fax

Practice location:
  • Phone: 919-470-7006
  • Fax:
Mailing address:
  • Phone: 919-417-2420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberL001119
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL001119
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: