Provider Demographics
NPI:1093060378
Name:GRANT, KIRSTIN L (RD, CDE)
Entity Type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:L
Last Name:GRANT
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 BONNIE BRAE CT
Mailing Address - Street 2:
Mailing Address - City:GRANITE SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:10527-1022
Mailing Address - Country:US
Mailing Address - Phone:914-419-0425
Mailing Address - Fax:
Practice Address - Street 1:131 BONNIE BRAE CT
Practice Address - Street 2:
Practice Address - City:GRANITE SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:10527-1022
Practice Address - Country:US
Practice Address - Phone:914-419-0425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005008-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered