Provider Demographics
NPI:1174585962
Name:CARPENTER, PATRICIA L (RDCDE)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:RDCDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 N YATES ST.
Mailing Address - Street 2:POBOX 653
Mailing Address - City:ASHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62612
Mailing Address - Country:US
Mailing Address - Phone:217-476-3647
Mailing Address - Fax:
Practice Address - Street 1:2528 FARRAGUT DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1433
Practice Address - Country:US
Practice Address - Phone:217-787-8870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK31730Medicare PIN