Healthcare Provider Details

I. General information

NPI: 1043559982
Provider Name (Legal Business Name): KERI KARST RD, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2013
Last Update Date: 02/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N WESTHAVEN DR
OSHKOSH WI
54904-7668
US

IV. Provider business mailing address

100 N MAIN ST UNIT 312
OSHKOSH WI
54901-5264
US

V. Phone/Fax

Practice location:
  • Phone: 920-303-5626
  • Fax:
Mailing address:
  • Phone: 612-483-0424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number990292
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2556-29
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: