Provider Demographics
NPI:1831538263
Name:CROSS, KRISTIN NOELLE (RD, RN)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NOELLE
Last Name:CROSS
Suffix:
Gender:F
Credentials:RD, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4451 UPPER KOGRU DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-9743
Mailing Address - Country:US
Mailing Address - Phone:907-854-6617
Mailing Address - Fax:
Practice Address - Street 1:SUITE 107
Practice Address - Street 2:OPTIHEALTH MEDICAL CLINIC 1000 O'MALLEY DRIVE
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501
Practice Address - Country:US
Practice Address - Phone:907-350-8903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK202133V00000X
AK34503163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered