Provider Demographics
NPI:1932847928
Name:TART, LORISSA ALYCE (RDN)
Entity type:Individual
Prefix:
First Name:LORISSA
Middle Name:ALYCE
Last Name:TART
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:LORISSA
Other - Middle Name:ALYCE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:423 AVERASBORO DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-2694
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:423 AVERASBORO DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-2694
Practice Address - Country:US
Practice Address - Phone:919-285-6791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005890133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered