Provider Demographics
NPI:1629730866
Name:LAKE, CARYN MCBRIDE (RDN)
Entity Type:Individual
Prefix:MRS
First Name:CARYN
Middle Name:MCBRIDE
Last Name:LAKE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11576 CRIPPLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BERRY
Mailing Address - State:AL
Mailing Address - Zip Code:35546-4422
Mailing Address - Country:US
Mailing Address - Phone:205-292-5108
Mailing Address - Fax:
Practice Address - Street 1:809 UNIVERSITY BLVD E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2029
Practice Address - Country:US
Practice Address - Phone:205-292-5108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1353133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered