Provider Demographics
NPI:1619284528
Name:LOSURE, CAROLYN M (MS,RD,CDE,CD-N)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:LOSURE
Suffix:
Gender:F
Credentials:MS,RD,CDE,CD-N
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 914
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-0914
Mailing Address - Country:US
Mailing Address - Phone:203-266-6420
Mailing Address - Fax:203-266-6636
Practice Address - Street 1:500 CHASE PKWY
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3346
Practice Address - Country:US
Practice Address - Phone:203-266-6420
Practice Address - Fax:203-266-6636
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000084133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT710000072Medicare UPIN