MEDICARE: KRISTINA FRESHOUR RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	86151636	NY

General Provider Information

NPI Number	:	1013655976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINA FRESHOUR RD

Provider Business Mailing Address
First Line	:	90 STATE ST STE OFFICE40
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12207-1716
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 WYNDOVER WOODS LN APT 1
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10603-3155
Country	:	US
Telephone Number	:	631-338-8760
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2022
Last Update Date	:	05/21/2022

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