Provider Demographics
NPI:1164706917
Name:BLUNK, KRYSTLE LEIGH (RD)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:LEIGH
Last Name:BLUNK
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 1:1121 DANFORTH DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6231
Mailing Address - Country:US
Mailing Address - Phone:417-631-9897
Mailing Address - Fax:
Practice Address - Street 1:620 E MONROE ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-2919
Practice Address - Country:US
Practice Address - Phone:573-582-8351
Practice Address - Fax:573-582-3335
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1011685133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1011685OtherCOMMISSION ON DIETETIC REGISTRATION