Provider Demographics
NPI:1558648501
Name:FLACK, CARRIE LYNNE (MS, RD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:LYNNE
Last Name:FLACK
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W PADRE ST APT E8
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-4250
Mailing Address - Country:US
Mailing Address - Phone:805-232-7296
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 588, M/C 7002
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93106-2662
Practice Address - Country:US
Practice Address - Phone:805-893-7051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01058061133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered