Provider Demographics
NPI:1356446231
Name:BAKER, CHARLOTTE (RD)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 EARL FRYE BLVD
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-5500
Mailing Address - Country:US
Mailing Address - Phone:662-256-6261
Mailing Address - Fax:662-256-6181
Practice Address - Street 1:1105 EARL FRYE BLVD
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-5500
Practice Address - Country:US
Practice Address - Phone:662-256-6261
Practice Address - Fax:662-256-6181
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD461133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSQ16419Medicare UPIN