Provider Demographics
NPI:1447427455
Name:MAITLEN, CARLY DENISE (RD)
Entity type:Individual
Prefix:MS
First Name:CARLY
Middle Name:DENISE
Last Name:MAITLEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6153 PERIDOT AVE
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701
Mailing Address - Country:US
Mailing Address - Phone:909-427-7185
Mailing Address - Fax:909-427-4151
Practice Address - Street 1:9961 SIERRA AVE
Practice Address - Street 2:FOOD AND NUTRITION SERVICES
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335
Practice Address - Country:US
Practice Address - Phone:909-427-7185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00966300133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered