Provider Demographics
NPI:1376734988
Name:FYNAN, CARLA LEE (RD)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:LEE
Last Name:FYNAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 KENSINGTON DR
Mailing Address - Street 2:
Mailing Address - City:EASTAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-4344
Mailing Address - Country:US
Mailing Address - Phone:609-702-0710
Mailing Address - Fax:609-702-0663
Practice Address - Street 1:13 KENSINGTON DR
Practice Address - Street 2:
Practice Address - City:EASTAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08060-4344
Practice Address - Country:US
Practice Address - Phone:609-702-0710
Practice Address - Fax:609-702-0663
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ807000133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered