Healthcare Provider Details

I. General information

NPI: 1548399074
Provider Name (Legal Business Name): KRISTAN LEE PONTILLO R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 N SUNRISE AVE STE 1205
ROSEVILLE CA
95661-2932
US

IV. Provider business mailing address

8890 GOLD BLOSSOM LN
NEWCASTLE CA
95658-9457
US

V. Phone/Fax

Practice location:
  • Phone: 916-624-3871
  • Fax:
Mailing address:
  • Phone: 530-888-8207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number715415
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: