Provider Demographics
NPI:1679079974
Name:BALKENBUSH, KAROLINA
Entity Type:Individual
Prefix:
First Name:KAROLINA
Middle Name:
Last Name:BALKENBUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5761 S FORT APACHE RD
Mailing Address - Street 2:BLD 8
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5506
Mailing Address - Country:US
Mailing Address - Phone:702-341-6610
Mailing Address - Fax:702-341-6961
Practice Address - Street 1:5761 S FORT APACHE RD
Practice Address - Street 2:BLD 8
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5506
Practice Address - Country:US
Practice Address - Phone:702-341-6610
Practice Address - Fax:702-341-6961
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV32626-DI-2OtherLICENSE