Provider Demographics
NPI:1295552206
Name:KISSEL, CAROLYN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:KISSEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:KISSEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:2 GOLDRING PL
Mailing Address - Street 2:
Mailing Address - City:ROLLING HILLS ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-2505
Mailing Address - Country:US
Mailing Address - Phone:310-990-0983
Mailing Address - Fax:
Practice Address - Street 1:2 GOLDRING PL
Practice Address - Street 2:
Practice Address - City:ROLLING HILLS ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-2505
Practice Address - Country:US
Practice Address - Phone:310-990-0983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-21
Last Update Date:2024-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86433239133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered