Provider Demographics
NPI:1952571903
Name:COLLYMORE, CHRISTINE (RD, LD, CSP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:COLLYMORE
Suffix:
Gender:F
Credentials:RD, LD, CSP
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:CASTELLANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2492 STANLEY RD
Mailing Address - Street 2:
Mailing Address - City:JBSA FT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-5500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-1092
Practice Address - Fax:210-916-5634
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80391133V00000X, 133VN1006X, 133VN1004X
133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic