Provider Demographics
NPI:1578819041
Name:MATALA, NICOLE MARIE (MS, RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MARIE
Last Name:MATALA
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:ROJENCHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2620 NEW BERN AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1821
Mailing Address - Country:US
Mailing Address - Phone:919-255-6721
Mailing Address - Fax:
Practice Address - Street 1:212 S SALEM ST
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-1825
Practice Address - Country:US
Practice Address - Phone:919-362-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003997133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered