Provider Demographics
NPI:1235581000
Name:DEFURIA, CARLA MARIE (MBA, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:MARIE
Last Name:DEFURIA
Suffix:
Gender:F
Credentials:MBA, RDN, LDN
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 3266
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3266
Mailing Address - Country:US
Mailing Address - Phone:904-819-4602
Mailing Address - Fax:
Practice Address - Street 1:351 TOWN PLAZA AVE STE 105
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-5179
Practice Address - Country:US
Practice Address - Phone:904-819-3233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 7872133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered