Healthcare Provider Details

I. General information

NPI: 1013300607
Provider Name (Legal Business Name): KRISTA ENGEN MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTA SHAWRON

II. Dates (important events)

Enumeration Date: 03/06/2015
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S WOOD ST FL MC85612
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

840 S WOOD ST FL MC85612
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-355-0732
  • Fax: 312-355-0739
Mailing address:
  • Phone: 312-355-0732
  • Fax: 312-355-0739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number164.005557
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: