Provider Demographics
NPI:1497997159
Name:ATCHISON, CAROL DIANE (RDLD, CSO, CDE, CNSD)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:DIANE
Last Name:ATCHISON
Suffix:
Gender:F
Credentials:RDLD, CSO, CDE, CNSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5957 W. 33RD SOUTH
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-5682
Mailing Address - Country:US
Mailing Address - Phone:208-313-1994
Mailing Address - Fax:208-552-3341
Practice Address - Street 1:5957 W. 33RD SOUTH
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-5682
Practice Address - Country:US
Practice Address - Phone:208-313-1994
Practice Address - Fax:208-552-3341
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-278133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered