Provider Demographics
NPI:1134508682
Name:DAVIS, KRISTEN (MS, RD, CDN)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 IRVING AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5413 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-2100
Practice Address - Country:US
Practice Address - Phone:315-727-9251
Practice Address - Fax:315-293-2791
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008367-1133VN1006X
NY008367133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered