Provider Demographics
NPI:1447574173
Name:LEWIS, KRISTIN (RD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:LEWIS
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 10214
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0214
Mailing Address - Country:US
Mailing Address - Phone:928-772-8652
Mailing Address - Fax:928-772-8078
Practice Address - Street 1:8508 N PRAIRIE VW
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86315-9089
Practice Address - Country:US
Practice Address - Phone:928-772-8652
Practice Address - Fax:928-772-8078
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ920049133V00000X, 133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ507248Medicaid
AZ507248Medicaid