Provider Demographics
NPI:1629180724
Name:WONN, KIRSTEN (RD/LDN)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:WONN
Suffix:
Gender:F
Credentials:RD/LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 SE 14TH DR
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-7231
Mailing Address - Country:US
Mailing Address - Phone:954-249-4086
Mailing Address - Fax:
Practice Address - Street 1:780 SW 24TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33315-2643
Practice Address - Country:US
Practice Address - Phone:954-762-3651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 3203133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered