Healthcare Provider Details

I. General information

NPI: 1669333704
Provider Name (Legal Business Name): MARY KATHERINE WILLIS RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2025
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 BRETONSHIRE RD
WILMINGTON NC
28405-4005
US

IV. Provider business mailing address

2559 CROQUET DR UNIT 8
WILMINGTON NC
28412-5178
US

V. Phone/Fax

Practice location:
  • Phone: 252-229-1870
  • Fax:
Mailing address:
  • Phone: 252-229-1870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: