Provider Demographics
NPI:1629221395
Name:CARLISLE, JOAN PIETRON (LRD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:PIETRON
Last Name:CARLISLE
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 32ND ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7868
Mailing Address - Country:US
Mailing Address - Phone:701-232-1572
Mailing Address - Fax:
Practice Address - Street 1:2121 ELM STREET NORTH
Practice Address - Street 2:FARGO VA MEDICAL CENTER
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-239-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND111133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered