Healthcare Provider Details

I. General information

NPI: 1942165659
Provider Name (Legal Business Name): KATHRYN WISTUBA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2659 STATE ST STE 100
CARLSBAD CA
92008-1627
US

IV. Provider business mailing address

3214 N BLAIR AVE
ROYAL OAK MI
48073-3560
US

V. Phone/Fax

Practice location:
  • Phone: 619-350-6290
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86298751
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: