Provider Demographics
NPI:1306179189
Name:ELLIOTT, CAROL H (RD, LD/N)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:H
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:RD, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 LAKE VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-6785
Mailing Address - Country:US
Mailing Address - Phone:386-673-2915
Mailing Address - Fax:368-676-1714
Practice Address - Street 1:725 W GRANADA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9406
Practice Address - Country:US
Practice Address - Phone:386-673-2915
Practice Address - Fax:368-676-1714
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 215133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered