Healthcare Provider Details

I. General information

NPI: 1760092753
Provider Name (Legal Business Name): ELISE JUDITH CARLSON MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 RICHMOND HWY # 800
ARLINGTON VA
22202-3603
US

IV. Provider business mailing address

1601 CLARENDON BLVD # C610
ARLINGTON VA
22209-2821
US

V. Phone/Fax

Practice location:
  • Phone: 571-257-3378
  • Fax:
Mailing address:
  • Phone: 540-446-3935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: