Healthcare Provider Details

I. General information

NPI: 1417287673
Provider Name (Legal Business Name): KRISTIN J WILKES RD, CDOE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2010
Last Update Date: 01/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 KAREE CT
WAKEFIELD RI
02879-2350
US

IV. Provider business mailing address

31 KAREE CT
WAKEFIELD RI
02879-2350
US

V. Phone/Fax

Practice location:
  • Phone: 401-862-5886
  • Fax:
Mailing address:
  • Phone: 401-862-5886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberLDN00402
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDN00402
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: