Basic Information
| Provider Information | |||||||||
| NPI: | 1629221395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLISLE | ||||||||
| FirstName: | JOAN | ||||||||
| MiddleName: | PIETRON | ||||||||
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| Credential: | LRD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2721 32ND ST S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581037868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012321572 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2121 ELM STREET NORTH | ||||||||
| Address2: | FARGO VA MEDICAL CENTER | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012393700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2008 | ||||||||
| LastUpdateDate: | 10/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 111 | ND | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.