Provider Demographics
NPI:1801210885
Name:COLEMAN, CARMEN
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:COLEMAN
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:PO BOX 19036
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76119-1036
Mailing Address - Country:US
Mailing Address - Phone:682-703-2449
Mailing Address - Fax:
Practice Address - Street 1:2351 PATHWAY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119-2743
Practice Address - Country:US
Practice Address - Phone:682-703-2449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist