Provider Demographics
NPI:1710101324
Name:KWAK, KRISTIN A (MS, RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:A
Last Name:KWAK
Suffix:
Gender:F
Credentials:MS, 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:PO BOX 404
Mailing Address - Street 2:
Mailing Address - City:HOLICONG
Mailing Address - State:PA
Mailing Address - Zip Code:18928-0404
Mailing Address - Country:US
Mailing Address - Phone:267-879-5148
Mailing Address - Fax:
Practice Address - Street 1:4950 YORK RD
Practice Address - Street 2:SUITE 2D-1
Practice Address - City:HOLICONG
Practice Address - State:PA
Practice Address - Zip Code:18928-6000
Practice Address - Country:US
Practice Address - Phone:267-879-5148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001674133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
723015OtherDIETETIC REGISTRATION NUM