Healthcare Provider Details

I. General information

NPI: 1144859216
Provider Name (Legal Business Name): KRISTEN ANNE COLEMAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N. FRESNO SUITE 370
FRESNO CA
93701-9370
US

IV. Provider business mailing address

215 N. FRESNO SUITE 370
FRESNO CA
93701
US

V. Phone/Fax

Practice location:
  • Phone: 559-459-4543
  • Fax: 559-459-1539
Mailing address:
  • Phone: 559-459-4543
  • Fax: 559-459-1539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number0997840
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: