Provider Demographics
NPI:1801644984
Name:WAMBLE, CARRIE DEA (RD LD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:DEA
Last Name:WAMBLE
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 1:106 HEATHER ST
Mailing Address - Street 2:
Mailing Address - City:BERTRAND
Mailing Address - State:MO
Mailing Address - Zip Code:63823-9766
Mailing Address - Country:US
Mailing Address - Phone:573-233-4215
Mailing Address - Fax:
Practice Address - Street 1:3095 LEXINGTON AVE STE 200
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2629
Practice Address - Country:US
Practice Address - Phone:573-987-5355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024008981133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered