Provider Demographics
NPI:1659849602
Name:CRADDOCK, KRYSTEN NYKOLE (RDN)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTEN
Middle Name:NYKOLE
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 SUNNY BROOK WAY
Mailing Address - Street 2:
Mailing Address - City:ADDY
Mailing Address - State:WA
Mailing Address - Zip Code:99101-6000
Mailing Address - Country:US
Mailing Address - Phone:509-991-2324
Mailing Address - Fax:
Practice Address - Street 1:36 KLONDIKE RD
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:WA
Practice Address - Zip Code:99166-9701
Practice Address - Country:US
Practice Address - Phone:509-775-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1018437133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered