Provider Demographics
NPI:1962532481
Name:KIM, CRISTINA (LD, MPH)
Entity type:Individual
Prefix:
First Name:CRISTINA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:LD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 HUNTCREST WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-8150
Mailing Address - Country:US
Mailing Address - Phone:678-491-3411
Mailing Address - Fax:678-473-7770
Practice Address - Street 1:1160 OLD PEACHTREE RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-5125
Practice Address - Country:US
Practice Address - Phone:678-473-7770
Practice Address - Fax:678-473-1066
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002593133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered