Provider Demographics
NPI:1619129970
Name:HIXSON, MARY GRAY (MPH, RD, LDN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GRAY
Last Name:HIXSON
Suffix:
Gender:F
Credentials:MPH, RD, LDN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:GRAY
Other - Last Name:HUTCHISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2800 BLUE RIDGE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6478
Mailing Address - Country:US
Mailing Address - Phone:919-784-7874
Mailing Address - Fax:919-784-2708
Practice Address - Street 1:4207 LAKE BOONE TRL STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6685
Practice Address - Country:US
Practice Address - Phone:919-784-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003135133V00000X, 133VN1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ37160D243Medicare PIN
NCQ37160AMedicare PIN