Healthcare Provider Details

I. General information

NPI: 1336789064
Provider Name (Legal Business Name): KRISTEN RENEE KISTLER MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2020
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4207 LAKE BOONE TRL STE 100
RALEIGH NC
27607-6685
US

IV. Provider business mailing address

4207 LAKE BOONE TRL STE 100
RALEIGH NC
27607-6685
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-7874
  • Fax:
Mailing address:
  • Phone: 919-784-7874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL005868
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: