Provider Demographics
NPI:1063939734
Name:JUNGLES, CARLY ANN (RD, LD)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ANN
Last Name:JUNGLES
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MN
Mailing Address - Zip Code:56352-1043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 MAIN ST W
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MN
Practice Address - Zip Code:56352-1043
Practice Address - Country:US
Practice Address - Phone:320-352-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3442133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered