Provider Demographics
NPI:1790343127
Name:METCALF, CARLY RUTH (RD, LD)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:RUTH
Last Name:METCALF
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 E 50TH ST APT D304
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83714-1425
Mailing Address - Country:US
Mailing Address - Phone:907-854-0612
Mailing Address - Fax:
Practice Address - Street 1:3562 S TK AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-5278
Practice Address - Country:US
Practice Address - Phone:907-854-0612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1129133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered