Provider Demographics
NPI:1053892018
Name:FLETCHER, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:KIEHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:245 E WENTWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2848
Mailing Address - Country:US
Mailing Address - Phone:501-519-0835
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-587-4017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10446634-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered