Provider Demographics
NPI:1508584491
Name:ETTINGER, CARRIE JEAN (CNS)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:JEAN
Last Name:ETTINGER
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:ST MICHAELS
Mailing Address - State:MD
Mailing Address - Zip Code:21663-0417
Mailing Address - Country:US
Mailing Address - Phone:301-442-2315
Mailing Address - Fax:
Practice Address - Street 1:115 E CHEW AVE
Practice Address - Street 2:
Practice Address - City:ST MICHAELS
Practice Address - State:MD
Practice Address - Zip Code:21663
Practice Address - Country:US
Practice Address - Phone:301-442-2315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX5442133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist