Provider Demographics
NPI:1033779814
Name:JEARLS, KRISTIE (RD)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:JEARLS
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 1:6211 BUCKLAND MILL RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-6709
Mailing Address - Country:US
Mailing Address - Phone:540-798-3108
Mailing Address - Fax:540-362-3766
Practice Address - Street 1:2602 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1010
Practice Address - Country:US
Practice Address - Phone:540-798-3108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA819055133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered