Provider Demographics
NPI:1962040683
Name:BAWOL, KRISTYN LENORE (RD)
Entity Type:Individual
Prefix:MISS
First Name:KRISTYN
Middle Name:LENORE
Last Name:BAWOL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 MARQUETTE AVE NE APT 303
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1489
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO DR SE RM 1047
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5180
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered