Provider Demographics
NPI:1821707654
Name:CARLSON, NICOLE G (RD, LD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:G
Last Name:CARLSON
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 1:2817 SUN TER
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-1861
Mailing Address - Country:US
Mailing Address - Phone:507-525-5066
Mailing Address - Fax:
Practice Address - Street 1:2817 SUN TER
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-1861
Practice Address - Country:US
Practice Address - Phone:507-525-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3265133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered