Provider Demographics
NPI:1083184527
Name:BLEVINS, CARLYN ANGELA (MS, RD)
Entity Type:Individual
Prefix:MISS
First Name:CARLYN
Middle Name:ANGELA
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 ELKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-2413
Mailing Address - Country:US
Mailing Address - Phone:619-444-1833
Mailing Address - Fax:
Practice Address - Street 1:231 ELKWOOD AVE
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-2413
Practice Address - Country:US
Practice Address - Phone:619-444-1833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86087991133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered