MEDICARE: KRISTEN KAY NEBERGALL 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

General Provider Information

NPI Number	:	1497063309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN KAY NEBERGALL RD

Provider Business Mailing Address
First Line	:	1512 WHITTERS WAY NW
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52405-1543
Country	:	US
Telephone Number	:	319-899-3644
Fax Number	:

Provider Business Practice Location Address
First Line	:	1512 WHITTERS WAY NW
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52405-1543
Country	:	US
Telephone Number	:	319-899-3644
Fax Number	:

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

Provider Enumeration Date	:	09/14/2010
Last Update Date	:	09/14/2010

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