Provider Demographics
NPI:1871713198
Name:PATTERSON, CARLA RAE (RD)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:RAE
Last Name:PATTERSON
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 1:1495 W STARLING AVE
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8818
Mailing Address - Country:US
Mailing Address - Phone:208-686-1931
Mailing Address - Fax:
Practice Address - Street 1:1115 B STREET
Practice Address - Street 2:
Practice Address - City:PLUMMER
Practice Address - State:ID
Practice Address - Zip Code:83851
Practice Address - Country:US
Practice Address - Phone:208-686-1931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD496133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered