Healthcare Provider Details

I. General information

NPI: 1932185378
Provider Name (Legal Business Name): HEATHER RENEE CUPP R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 FORESTVILLE RD
RALEIGH NC
27616-8774
US

IV. Provider business mailing address

PO BOX 602195
CHARLOTTE NC
28260-2195
US

V. Phone/Fax

Practice location:
  • Phone: 919-235-6550
  • Fax:
Mailing address:
  • Phone: 877-498-4490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL006978
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: