Provider Demographics
NPI:1417340548
Name:NELSON, KIRSTIN (RD)
Entity type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3054
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-3054
Mailing Address - Country:US
Mailing Address - Phone:509-826-1550
Mailing Address - Fax:509-826-1525
Practice Address - Street 1:638 OKOMA DR
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9525
Practice Address - Country:US
Practice Address - Phone:509-826-1550
Practice Address - Fax:509-826-1525
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ175417Medicaid
AZZ195175Medicare PIN
AZZ199081Medicare PIN