MEDICARE: ANDREA CARLISLE RDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	L006081	NC

General Provider Information

NPI Number	:	1124731195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA CARLISLE RDN

Provider Business Mailing Address
First Line	:	319 FAYETTEVILLE ST UNIT 415
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27601-1976
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1603 HILLSBOROUGH ST
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27605
Country	:	US
Telephone Number	:	919-604-6690
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2023
Last Update Date	:	01/04/2023

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