Provider Demographics
NPI:1184953267
Name:PENNISTON, KRISTINA LEA (RD, PHD)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LEA
Last Name:PENNISTON
Suffix:
Gender:F
Credentials:RD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:F4/320 CLINICAL SCIENCE CENTER
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-3236
Practice Address - Country:US
Practice Address - Phone:608-265-9797
Practice Address - Fax:608-262-6453
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-18
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1444-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1444-029OtherRD, PHD