Provider Demographics
NPI:1548608243
Name:OTT, KRISTINE LEE (RD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:LEE
Last Name:OTT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:LEE
Other - Last Name:ONKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:4986 N ADAMS RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-5017
Mailing Address - Country:US
Mailing Address - Phone:284-475-4701
Mailing Address - Fax:248-475-5777
Practice Address - Street 1:4986 N ADAMS RD
Practice Address - Street 2:SUITE E
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48306-5017
Practice Address - Country:US
Practice Address - Phone:248-475-2401
Practice Address - Fax:248-475-5777
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01012955133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered