Provider Demographics
NPI:1083326805
Name:NEVILLE, KRISTY ELAINE (RDNLD)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:ELAINE
Last Name:NEVILLE
Suffix:
Gender:F
Credentials:RDNLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 W KIRKPATRICK ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076-1631
Mailing Address - Country:US
Mailing Address - Phone:816-263-2553
Mailing Address - Fax:
Practice Address - Street 1:615 W KIRKPATRICK ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:MO
Practice Address - Zip Code:64076-1631
Practice Address - Country:US
Practice Address - Phone:816-263-2553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO811705133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered