Provider Demographics
NPI:1003191735
Name:FREDERICKS, KRISTEL JUNE (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEL
Middle Name:JUNE
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3133 GOOD SHEPHERD WAY
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7921
Mailing Address - Country:US
Mailing Address - Phone:903-323-6541
Mailing Address - Fax:903-323-6564
Practice Address - Street 1:3133 GOOD SHEPHERD WAY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7921
Practice Address - Country:US
Practice Address - Phone:903-323-6541
Practice Address - Fax:903-323-6564
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82118133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered