Healthcare Provider Details

I. General information

NPI: 1740717487
Provider Name (Legal Business Name): KRISTA HEUTON RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 S CLARK ST
CARROLL IA
51401-3038
US

IV. Provider business mailing address

311 S CLARK ST
CARROLL IA
51401-3038
US

V. Phone/Fax

Practice location:
  • Phone: 712-794-5283
  • Fax:
Mailing address:
  • Phone: 712-794-5283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number076140
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: