Provider Demographics
NPI:1871775015
Name:RICHARDSON, CARLA SUE (RD)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:SUE
Last Name:RICHARDSON
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:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-0095
Mailing Address - Country:US
Mailing Address - Phone:970-986-2677
Mailing Address - Fax:
Practice Address - Street 1:2121 NORTH AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6428
Practice Address - Country:US
Practice Address - Phone:970-244-1319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO599775133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered