Healthcare Provider Details

I. General information

NPI: 1467597278
Provider Name (Legal Business Name): STACY CADDELL COVINGTON MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 MEMORIAL DR
PINEHURST NC
28374-8710
US

IV. Provider business mailing address

PO BOX 8500
PINEHURST NC
28374-8500
US

V. Phone/Fax

Practice location:
  • Phone: 910-255-3668
  • Fax: 910-255-3695
Mailing address:
  • Phone: 910-715-1010
  • Fax: 910-715-1026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL002960
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: