Provider Demographics
NPI:1326674789
Name:MELLETTE, THOMAS (MS, RD, LDN, CNSC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MELLETTE
Suffix:
Gender:M
Credentials:MS, RD, LDN, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11220 N RADNER WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-5530
Mailing Address - Country:US
Mailing Address - Phone:919-213-0161
Mailing Address - Fax:
Practice Address - Street 1:11220 N RADNER WAY
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-5530
Practice Address - Country:US
Practice Address - Phone:919-213-0161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-18
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005168133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered