Provider Demographics
NPI:1487099511
Name:STARBUCK, TERAH NICOLE
Entity type:Individual
Prefix:MRS
First Name:TERAH
Middle Name:NICOLE
Last Name:STARBUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 EMERYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-4142
Mailing Address - Country:US
Mailing Address - Phone:336-692-8080
Mailing Address - Fax:
Practice Address - Street 1:428 E 4TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2434
Practice Address - Country:US
Practice Address - Phone:704-380-4655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003814133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered