Provider Demographics
NPI:1043524689
Name:SIMONETTI, KRISTA MARIE (MS, CNS)
Entity Type:Individual
Prefix:MS
First Name:KRISTA
Middle Name:MARIE
Last Name:SIMONETTI
Suffix:
Gender:F
Credentials:MS, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15801 S 48TH ST
Mailing Address - Street 2:APT 2212
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0807
Mailing Address - Country:US
Mailing Address - Phone:480-204-6006
Mailing Address - Fax:
Practice Address - Street 1:540 N CAMINO MERCADO
Practice Address - Street 2:SUITE 3
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5751
Practice Address - Country:US
Practice Address - Phone:520-840-4026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCNS-16014133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ143285Medicare PIN