Provider Demographics
NPI:1033807557
Name:KOENIG, TRAVIS (RD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:KOENIG
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 AVENT FERRY RD APT F
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-3119
Mailing Address - Country:US
Mailing Address - Phone:910-398-2673
Mailing Address - Fax:
Practice Address - Street 1:2501 AVENT FERRY RD APT F
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-3119
Practice Address - Country:US
Practice Address - Phone:910-398-2673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered