Provider Demographics
NPI:1871649251
Name:BURKE, CAROL W (RD, LD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:W
Last Name:BURKE
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 1:9142 S HAMMOCK AVE
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-9040
Mailing Address - Country:US
Mailing Address - Phone:352-726-5222
Mailing Address - Fax:352-637-5397
Practice Address - Street 1:3700 W SOVEREIGN PATH
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-8071
Practice Address - Country:US
Practice Address - Phone:352-726-1731
Practice Address - Fax:352-637-5397
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND2085133NN1002X
FLR345521133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8908ZMedicare ID - Type Unspecified