Provider Demographics
NPI:1164787180
Name:SANDERS, CARRIE D (RD, LD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:D
Last Name:SANDERS
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E MAINE AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-5915
Mailing Address - Country:US
Mailing Address - Phone:580-540-9830
Mailing Address - Fax:
Practice Address - Street 1:701 E MAINE AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5915
Practice Address - Country:US
Practice Address - Phone:580-540-9830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2015-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1378133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK370016Medicare PIN