Provider Demographics
NPI:1306911474
Name:CARLSON, KAREN A
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:A
Last Name:CARLSON
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 1:603 E KILDARE DR
Mailing Address - Street 2:
Mailing Address - City:ONEILL
Mailing Address - State:NE
Mailing Address - Zip Code:68763-1143
Mailing Address - Country:US
Mailing Address - Phone:402-336-1363
Mailing Address - Fax:
Practice Address - Street 1:300 N 2ND ST
Practice Address - Street 2:
Practice Address - City:ONEILL
Practice Address - State:NE
Practice Address - Zip Code:68763-1514
Practice Address - Country:US
Practice Address - Phone:402-336-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE35133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE275821Medicare ID - Type UnspecifiedPERFORMING NUMBER
NE092573Medicare ID - Type UnspecifiedAVERA ST ANTHONY'S GROUP