Healthcare Provider Details

I. General information

NPI: 1942078274
Provider Name (Legal Business Name): KRISTEN FUSTOS MS, RDN, CSP, LD,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN GOOCH

II. Dates (important events)

Enumeration Date: 12/15/2023
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 130334
TAMPA FL
33681-0334
US

IV. Provider business mailing address

PO BOX 130334
TAMPA FL
33681-0334
US

V. Phone/Fax

Practice location:
  • Phone: 813-590-7565
  • Fax: 813-219-8055
Mailing address:
  • Phone: 813-590-7565
  • Fax: 813-219-8055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND9388
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberALPP-319150
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number86118144
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: