Provider Demographics
NPI:1184815318
Name:DECKER, CAROLYN GENETTE (LD)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:GENETTE
Last Name:DECKER
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 665
Mailing Address - Street 2:
Mailing Address - City:DASSEL
Mailing Address - State:MN
Mailing Address - Zip Code:55325-0665
Mailing Address - Country:US
Mailing Address - Phone:320-275-2068
Mailing Address - Fax:
Practice Address - Street 1:241 ATLANTIC AVENUE EAST
Practice Address - Street 2:
Practice Address - City:DASSEL
Practice Address - State:MN
Practice Address - Zip Code:55325-0000
Practice Address - Country:US
Practice Address - Phone:320-275-2068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1391133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist