Provider Demographics
NPI:1053639062
Name:THOMPSON, CARRIE (RD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:M
Other - Last Name:GARDACHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:5153 N 9TH AVE STE 5G
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8785
Practice Address - Country:US
Practice Address - Phone:850-416-2117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND11513133V00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117627600Medicaid
LA3B778Medicare PIN