Provider Demographics
NPI:1548399074
Name:PONTILLO, KRISTAN LEE (RD)
Entity Type:Individual
Prefix:MRS
First Name:KRISTAN
Middle Name:LEE
Last Name:PONTILLO
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 1:8890 GOLD BLOSSOM LN
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:CA
Mailing Address - Zip Code:95658-9457
Mailing Address - Country:US
Mailing Address - Phone:530-888-8207
Mailing Address - Fax:
Practice Address - Street 1:151 N SUNRISE AVE
Practice Address - Street 2:STE 1205
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2932
Practice Address - Country:US
Practice Address - Phone:916-624-3871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA715415133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ26830ZMedicare ID - Type UnspecifiedMEDICAL NUTRITION THERAPY