Provider Demographics
NPI:1881411544
Name:REISTAD, CIARA NICOLE (MS, RDN, LDN)
Entity type:Individual
Prefix:
First Name:CIARA
Middle Name:NICOLE
Last Name:REISTAD
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 HARBOR BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2351
Mailing Address - Country:US
Mailing Address - Phone:760-777-5229
Mailing Address - Fax:
Practice Address - Street 1:385 HARBOR BLVD STE 220
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2351
Practice Address - Country:US
Practice Address - Phone:760-777-5229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13349133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered