Healthcare Provider Details

I. General information

NPI: 1801333935
Provider Name (Legal Business Name): KRISTINA COUGHLIN MS, RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20748 BOULDERFIELD AVE
BEND OR
97701-7327
US

IV. Provider business mailing address

20748 BOULDERFIELD AVE
BEND OR
97701-7327
US

V. Phone/Fax

Practice location:
  • Phone: 541-279-3696
  • Fax:
Mailing address:
  • Phone: 541-279-3696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10177506
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: