1114553062 NPI number — ANN MARYROSE CARLSON MS, RD, LMNT

Table of content: ANN MARYROSE CARLSON MS, RD, LMNT (NPI 1114553062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114553062 NPI number — ANN MARYROSE CARLSON MS, RD, LMNT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON
Provider First Name:
ANN
Provider Middle Name:
MARYROSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, RD, LMNT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BERRY
Provider Other First Name:
ANN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, RD, LMNT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114553062
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 MOUNT LOWE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAKERSFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93309-2468
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 MOUNT LOWE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKERSFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93309-2468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-699-8923
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  86116638 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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