Healthcare Provider Details

I. General information

NPI: 1174585962
Provider Name (Legal Business Name): PATRICIA L CARPENTER RDCDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2528 FARRAGUT DR
SPRINGFIELD IL
62704-1433
US

IV. Provider business mailing address

313 N YATES ST. POBOX 653
ASHLAND IL
62612
US

V. Phone/Fax

Practice location:
  • Phone: 217-787-8870
  • Fax:
Mailing address:
  • Phone: 217-476-3647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: