Provider Demographics
NPI:1952623324
Name:KRISTINE VAN WORKUM, RD, LDN, INC.
Entity Type:Organization
Organization Name:KRISTINE VAN WORKUM, RD, LDN, INC.
Other - Org Name:BREVARD NUTRITION, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:VAN WORKUM
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LDN
Authorized Official - Phone:443-253-3170
Mailing Address - Street 1:514 VERACRUZ BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4728
Mailing Address - Country:US
Mailing Address - Phone:443-253-3170
Mailing Address - Fax:321-327-7914
Practice Address - Street 1:107 N PALM AVE
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-3131
Practice Address - Country:US
Practice Address - Phone:321-327-7948
Practice Address - Fax:321-327-7914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 5470133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty