Healthcare Provider Details

I. General information

NPI: 1588215453
Provider Name (Legal Business Name): SARA WILBURN MS, RD, LD, CEDRD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1042 WASHINGTON ST
RALEIGH NC
27605-1258
US

IV. Provider business mailing address

5719 CLEARBAY LN
RALEIGH NC
27612-8601
US

V. Phone/Fax

Practice location:
  • Phone: 228-326-8713
  • Fax:
Mailing address:
  • Phone: 228-326-8713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL004909
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: