Healthcare Provider Details

I. General information

NPI: 1700415742
Provider Name (Legal Business Name): CARRIE A MCLEOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 12/14/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 19TH AVE N STE J, PMB 178
FARGO ND
58102-4878
US

IV. Provider business mailing address

1100 19TH AVE N STE 178
FARGO ND
58102-5906
US

V. Phone/Fax

Practice location:
  • Phone: 701-532-1683
  • Fax:
Mailing address:
  • Phone: 701-532-1683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number226
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: