Healthcare Provider Details

I. General information

NPI: 1639646367
Provider Name (Legal Business Name): CAROL MARY MEDINS MPH, RD, LDN, CNSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL MARY JENKINS

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WAKEMED RALEIGH MEDICAL PARK 23 SUNNYBROOK ROAD, SUITE 200
RALEIGH NC
27610
US

IV. Provider business mailing address

400 SCOTTS RIDGE TRL
APEX NC
27502-6584
US

V. Phone/Fax

Practice location:
  • Phone: 919-235-6435
  • Fax:
Mailing address:
  • Phone: 919-302-3648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberL002778
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: