Provider Demographics
NPI:1912633710
Name:CARPENTER, MIRANDA NATALIA (RD)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:NATALIA
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 PETALUMA AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4256
Mailing Address - Country:US
Mailing Address - Phone:707-823-3166
Mailing Address - Fax:
Practice Address - Street 1:652 PETALUMA AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4256
Practice Address - Country:US
Practice Address - Phone:707-823-3166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86198734133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered