Provider Demographics
NPI:1124715834
Name:MERRILL, KAREN A (MS, RD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:A
Last Name:MERRILL
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 FOREST LAKES DR
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-9248
Mailing Address - Country:US
Mailing Address - Phone:480-589-8749
Mailing Address - Fax:
Practice Address - Street 1:4004 FOREST LAKES DR
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-9248
Practice Address - Country:US
Practice Address - Phone:480-589-8749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO818724133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered