Provider Demographics
NPI:1598139123
Name:HISTED, CHRISTINE (RD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:HISTED
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:TAKALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5303 S CEDAR ST
Mailing Address - Street 2:BUILDING 1
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-3800
Mailing Address - Country:US
Mailing Address - Phone:517-887-1440
Mailing Address - Fax:
Practice Address - Street 1:5303 S CEDAR ST
Practice Address - Street 2:BUILDING 1
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-3800
Practice Address - Country:US
Practice Address - Phone:517-887-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI966145133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered