Healthcare Provider Details

I. General information

NPI: 1376855759
Provider Name (Legal Business Name): DORIS MARIA NICOLAS-MIR RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 ROCK QUARRY RD
RALEIGH NC
27610-3825
US

IV. Provider business mailing address

215 FIREWEED PL
CLAYTON NC
27527-4572
US

V. Phone/Fax

Practice location:
  • Phone: 919-833-5376
  • Fax:
Mailing address:
  • Phone: 919-585-2904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL003159
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: