Provider Demographics
NPI:1508647710
Name:WOLLMUTH, KRISTEN (RD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:WOLLMUTH
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 587
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:TX
Mailing Address - Zip Code:78629-0587
Mailing Address - Country:US
Mailing Address - Phone:830-672-7581
Mailing Address - Fax:830-672-2401
Practice Address - Street 1:1110 N SARAH DEWITT DR
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629-3311
Practice Address - Country:US
Practice Address - Phone:830-672-7581
Practice Address - Fax:830-672-2401
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86144109133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered