MEDICARE: CHRISTINE ALLEGRA GAST RDN, IBCLC

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	174N00000X	Lactation Consultant (Non-RN)	L-104867	VA
2	133V00000X	Registered Dietitian	ND8742	FL

General Provider Information

NPI Number	:	1053793158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE ALLEGRA GAST RDN, IBCLC

Provider Business Mailing Address
First Line	:	450 KANUHA DR
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-5027
Country	:	US
Telephone Number	:	808-681-9202
Fax Number	:	850-427-5782

Provider Business Practice Location Address
First Line	:	450 KANUHA DR
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-5027
Country	:	US
Telephone Number	:	808-681-9202
Fax Number	:	850-427-5782

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

Provider Enumeration Date	:	06/24/2015
Last Update Date	:	09/05/2019

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