Provider Demographics
NPI:1700415742
Name:MCLEOD, CARRIE A
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:A
Last Name:MCLEOD
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 1:1100 19TH AVE N STE 178
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-5906
Mailing Address - Country:US
Mailing Address - Phone:701-532-1683
Mailing Address - Fax:
Practice Address - Street 1:1100 19TH AVE N
Practice Address - Street 2:STE J, PMB 178
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4878
Practice Address - Country:US
Practice Address - Phone:701-532-1683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND226133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic