Provider Demographics
NPI:1255813580
Name:FITZGERALD, EDWARD GEORGE (RD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:GEORGE
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:EDWARD
Other - Middle Name:GEORGE
Other - Last Name:NICKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2501 BLUE RIDGE RD STE G130
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6347
Mailing Address - Country:US
Mailing Address - Phone:919-594-1885
Mailing Address - Fax:
Practice Address - Street 1:2501 BLUE RIDGE RD STE G130
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6347
Practice Address - Country:US
Practice Address - Phone:919-594-1885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005552133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered