Provider Demographics
NPI:1063286128
Name:ARBUCKLE, CAROLYN M
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:ARBUCKLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N STAFFORD ST APT 1112
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-4126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:585-683-0734
Practice Address - Street 1:900 N STAFFORD ST APT 1112
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-4126
Practice Address - Country:US
Practice Address - Phone:585-683-0734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDI100001180133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered