Provider Demographics
NPI:1033994033
Name:TEAGUE, MICAH NICOLE (RD)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:NICOLE
Last Name:TEAGUE
Suffix:
Gender:F
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:760 HIGHLAND OAKS DR STE 200
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7114
Practice Address - Country:US
Practice Address - Phone:336-277-4380
Practice Address - Fax:336-659-0659
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC007461133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered