Provider Demographics
NPI:1255316717
Name:KITSLAAR, LYNN M (RD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:M
Last Name:KITSLAAR
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:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5753
Practice Address - Country:US
Practice Address - Phone:920-430-4700
Practice Address - Fax:920-430-4747
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1399-29133VN1006X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20110340OtherNATIONAL CERTIFICATION BOARD FOR DIABETES EDUCATORS
WI850912OtherCOMMISSION ON DIETETIC REGISTRATION