Provider Demographics
NPI:1306323571
Name:BOLLER, KRISTI LYNN (DIETICIAN)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:LYNN
Last Name:BOLLER
Suffix:
Gender:F
Credentials:DIETICIAN
Other - Prefix:
Other - First Name:KRISTI
Other - Middle Name:
Other - Last Name:CROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DIETICIAN
Mailing Address - Street 1:3840 HULEN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7277
Mailing Address - Country:US
Mailing Address - Phone:817-569-4300
Mailing Address - Fax:
Practice Address - Street 1:3840 HULEN ST STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7269
Practice Address - Country:US
Practice Address - Phone:817-335-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82681133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered