Provider Demographics
NPI:1407071590
Name:WARD, CAROL E (RD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:E
Last Name:WARD
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 1:2090 N SUNNY LN
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5118
Mailing Address - Country:US
Mailing Address - Phone:208-794-8648
Mailing Address - Fax:
Practice Address - Street 1:2090 N SUNNY LN
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5118
Practice Address - Country:US
Practice Address - Phone:208-794-8648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD185133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0983730Medicaid