Provider Demographics
NPI:1508208562
Name:LONGFELLOW, KRISTIN (RD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:LONGFELLOW
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 1:609 MOCKINGBIRD CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7373
Mailing Address - Country:US
Mailing Address - Phone:903-521-4407
Mailing Address - Fax:
Practice Address - Street 1:1030 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9553
Practice Address - Country:US
Practice Address - Phone:601-936-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1467133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered