Healthcare Provider Details

I. General information

NPI: 1619474392
Provider Name (Legal Business Name): KRISTINE BERUBE RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 E 7TH ST
BOSTON MA
02127
US

IV. Provider business mailing address

710 E 7TH ST
BOSTON MA
02127-4349
US

V. Phone/Fax

Practice location:
  • Phone: 978-340-8834
  • Fax:
Mailing address:
  • Phone: 978-340-8834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberNU3872
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3872
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: