Provider Demographics
NPI:1932987328
Name:BAKER, FERN LEE (RD)
Entity Type:Individual
Prefix:MRS
First Name:FERN
Middle Name:LEE
Last Name:BAKER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:FERN
Other - Middle Name:LEE
Other - Last Name:PURVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:311 S MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:AR
Mailing Address - Zip Code:71671-2803
Mailing Address - Country:US
Mailing Address - Phone:870-820-5242
Mailing Address - Fax:
Practice Address - Street 1:311 S MYRTLE ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:AR
Practice Address - Zip Code:71671-2803
Practice Address - Country:US
Practice Address - Phone:870-820-5242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1873133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered