Basic Information
| Provider Information | |||||||||
| NPI: | 1366813990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARTLETT | ||||||||
| FirstName: | CARRISSA | ||||||||
| MiddleName: | GAIL | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 673MDG, 5955 ZEAMER AVENUE | ||||||||
| Address2: | |||||||||
| City: | JBER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075803205 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 673MDG, 5955 ZEAMER AVENUE | ||||||||
| Address2: | |||||||||
| City: | JBER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075803205 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2015 | ||||||||
| LastUpdateDate: | 03/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86012042 | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.