Provider Demographics
NPI:1104310036
Name:ELLIS, KRISTEN (RDN)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 BAYPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8518
Mailing Address - Country:US
Mailing Address - Phone:585-313-2952
Mailing Address - Fax:
Practice Address - Street 1:2121 BAYPOINTE DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8518
Practice Address - Country:US
Practice Address - Phone:585-313-2952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT135522106H00000X
CA135522106H00000X
CA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty