Provider Demographics
NPI:1558977017
Name:OTTO, KRISTIN (MS)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:OTTO
Suffix:
Gender:
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 MOODY ST STE 205
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-0401
Mailing Address - Country:US
Mailing Address - Phone:781-738-0571
Mailing Address - Fax:844-738-9026
Practice Address - Street 1:419 MOODY ST STE 205
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-0401
Practice Address - Country:US
Practice Address - Phone:781-738-0571
Practice Address - Fax:844-738-9026
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered