1154349363 NPI number — MS. KENNETTE MARIE CARLSON MBA, RD, CDN

Table of content: MS. KENNETTE MARIE CARLSON MBA, RD, CDN (NPI 1154349363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154349363 NPI number — MS. KENNETTE MARIE CARLSON MBA, RD, CDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON
Provider First Name:
KENNETTE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MBA, RD, CDN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154349363
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1186 NASH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH TONAWANDA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14120-2961
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-834-9200
Provider Business Mailing Address Fax Number:
716-862-6374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3495 BAILEY AVE
Provider Second Line Business Practice Location Address:
MAIL CODE 528/120
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14215-1129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-834-9200
Provider Business Practice Location Address Fax Number:
716-862-6374
Provider Enumeration Date:
07/17/2006

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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