Healthcare Provider Details

I. General information

NPI: 1245894906
Provider Name (Legal Business Name): KRISTINA KATHERINE COOKE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 AVENUE G APT 10
REDONDO BEACH CA
90277-6001
US

IV. Provider business mailing address

19908 MILDRED AVE
TORRANCE CA
90503-1124
US

V. Phone/Fax

Practice location:
  • Phone: 424-348-0475
  • Fax:
Mailing address:
  • Phone: 310-406-6350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number86069006
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number86069006
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number86069006
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86069006
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: