Provider Demographics
NPI:1851453351
Name:CARLSON, MARLI JEAN (RD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:MARLI
Middle Name:JEAN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-2151
Mailing Address - Country:US
Mailing Address - Phone:906-485-2118
Mailing Address - Fax:
Practice Address - Street 1:100 MALTON ST
Practice Address - Street 2:
Practice Address - City:NEGAUNEE
Practice Address - State:MI
Practice Address - Zip Code:49866-2001
Practice Address - Country:US
Practice Address - Phone:906-485-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI133NN1002X
MI818424133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N63910Medicare UPIN