Provider Demographics
NPI:1659882108
Name:LAVOIE, KRISTIN A (RD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:A
Last Name:LAVOIE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:18001 N 79TH AVE STE A12
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8398
Mailing Address - Country:US
Mailing Address - Phone:623-399-6825
Mailing Address - Fax:623-505-3474
Practice Address - Street 1:64 E BROADWAY RD STE 200
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1377
Practice Address - Country:US
Practice Address - Phone:623-399-6825
Practice Address - Fax:623-505-3474
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86060260133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicaid