Provider Demographics
NPI:1487320248
Name:VINES, CLARA GENE (RD, LDN)
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:GENE
Last Name:VINES
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SAINT ALBANS DR UNIT 436
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6676
Mailing Address - Country:US
Mailing Address - Phone:229-529-5975
Mailing Address - Fax:
Practice Address - Street 1:4208 SIX FORKS RD STE 1000
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-5738
Practice Address - Country:US
Practice Address - Phone:980-296-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL006540133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered