Provider Demographics
NPI:1508832791
Name:WILLIAMS, KRISTINE S (RD LD)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:S
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 OPHIR DR
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301
Mailing Address - Country:US
Mailing Address - Phone:970-382-0927
Mailing Address - Fax:
Practice Address - Street 1:12000 STONE LAKE RD
Practice Address - Street 2:DULCE HEALTH CENTER
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:505-759-3291
Practice Address - Fax:505-759-7289
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM468133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K3526Medicaid
NMHSZ196OtherMEDICARE PART B
NM56186878Medicaid
8HE371Medicare ID - Type Unspecified
NMHSZ196OtherMEDICARE PART B