Provider Demographics
NPI:1932721610
Name:CARLSON, DEIRDRE NICOLE (RDN)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:NICOLE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2745 DE OVAN AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-1419
Mailing Address - Country:US
Mailing Address - Phone:763-234-6196
Mailing Address - Fax:
Practice Address - Street 1:2745 DE OVAN AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-1419
Practice Address - Country:US
Practice Address - Phone:763-234-6196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1092827133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1092827OtherREGISTERED DIETITIAN/REGISTERED DIETITIAN NUTRITIONIST