Provider Demographics
NPI:1710574066
Name:WILKERSON, LUCAS (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 HIKING TRL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3913
Mailing Address - Country:US
Mailing Address - Phone:336-267-0065
Mailing Address - Fax:
Practice Address - Street 1:2810 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802-4447
Practice Address - Country:US
Practice Address - Phone:773-906-4773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005647133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered