Provider Demographics
NPI:1033363791
Name:KRISTAL, IRENE MICHELLE (RD)
Entity Type:Individual
Prefix:MS
First Name:IRENE
Middle Name:MICHELLE
Last Name:KRISTAL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21465 RUNNING BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3751
Mailing Address - Country:US
Mailing Address - Phone:805-300-0300
Mailing Address - Fax:
Practice Address - Street 1:21465 RUNNING BRANCH RD
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3751
Practice Address - Country:US
Practice Address - Phone:805-300-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA862117133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered