Healthcare Provider Details

I. General information

NPI: 1710101324
Provider Name (Legal Business Name): KRISTIN A. KWAK M.S., R.D., L.D.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 YORK RD SUITE 2D-1
HOLICONG PA
18928-6000
US

IV. Provider business mailing address

PO BOX 404
HOLICONG PA
18928-0404
US

V. Phone/Fax

Practice location:
  • Phone: 267-879-5148
  • Fax:
Mailing address:
  • Phone: 267-879-5148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN001674
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: