Provider Demographics
NPI:1508000266
Name:BACH, KRISTINE LOUISE (MS, RD, CDN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:LOUISE
Last Name:BACH
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 1:1 PATTY ANN CT
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8031
Mailing Address - Country:US
Mailing Address - Phone:631-474-8684
Mailing Address - Fax:631-474-8684
Practice Address - Street 1:1 PATTY ANN CT
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-8031
Practice Address - Country:US
Practice Address - Phone:631-474-8684
Practice Address - Fax:631-474-8684
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-26
Last Update Date:2009-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY714025133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered