Provider Demographics
NPI:1396840856
Name:CARSON, ELYSE MARIE (MS RD LD)
Entity Type:Individual
Prefix:MRS
First Name:ELYSE
Middle Name:MARIE
Last Name:CARSON
Suffix:
Gender:F
Credentials:MS RD LD
Other - Prefix:MRS
Other - First Name:ELYSE
Other - Middle Name:MARIE
Other - Last Name:TYLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS RD LD
Mailing Address - Street 1:6135 LA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-4310
Mailing Address - Country:US
Mailing Address - Phone:214-773-6858
Mailing Address - Fax:
Practice Address - Street 1:6135 LA VISTA DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-4310
Practice Address - Country:US
Practice Address - Phone:214-773-6858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDTO5996133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX896525OtherCDR
TXDTO5996OtherTEXAS LICENSURE
TX143738601Medicaid