Provider Demographics
NPI:1992283998
Name:REBURN, HEATHER (RDN, LDN)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:REBURN
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 S MEMORIAL DR STE B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-6224
Mailing Address - Country:US
Mailing Address - Phone:252-758-0721
Mailing Address - Fax:
Practice Address - Street 1:3005 S MEMORIAL DR STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-6224
Practice Address - Country:US
Practice Address - Phone:610-952-1503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005485133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered