Provider Demographics
NPI:1326661877
Name:GARD, KRISTINA-MARIE L (RD)
Entity Type:Individual
Prefix:
First Name:KRISTINA-MARIE
Middle Name:L
Last Name:GARD
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 1:4879 BRAEMAR ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-4700
Mailing Address - Country:US
Mailing Address - Phone:925-759-6293
Mailing Address - Fax:
Practice Address - Street 1:260 CALIFORNIA DR
Practice Address - Street 2:
Practice Address - City:YOUNTVILLE
Practice Address - State:CA
Practice Address - Zip Code:94599-1412
Practice Address - Country:US
Practice Address - Phone:707-948-3329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86106669133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered