Healthcare Provider Details

I. General information

NPI: 1578289047
Provider Name (Legal Business Name): KRISTA LARSEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 TULLIE RD NE FL 7
ATLANTA GA
30329-2309
US

IV. Provider business mailing address

1505 BROOKHAVEN CIR NE
BROOKHAVEN GA
30319-3114
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-2755
  • Fax:
Mailing address:
  • Phone: 706-599-2289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberLD005159
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: