Provider Demographics
NPI:1942665104
Name:NICKELS, KRISTEN (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:NICKELS
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1330 E CHERRY ST STE 106
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-3573
Mailing Address - Country:US
Mailing Address - Phone:417-766-0663
Mailing Address - Fax:417-765-0526
Practice Address - Street 1:1330 E CHERRY ST STE 210
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-3638
Practice Address - Country:US
Practice Address - Phone:417-766-0663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-15
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015020186133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered