Provider Demographics
NPI:1982034112
Name:PALMER, ILISSA MARIE (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:ILISSA
Middle Name:MARIE
Last Name:PALMER
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 PROVIDENCE RD APT C
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4456
Mailing Address - Country:US
Mailing Address - Phone:585-354-5449
Mailing Address - Fax:
Practice Address - Street 1:4102 PROVIDENCE RD APT C
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4456
Practice Address - Country:US
Practice Address - Phone:585-354-5449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004231133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered