Provider Demographics
NPI:1962874768
Name:LEBEAU, KRISTIE (RDN)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:LEBEAU
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 1:700 E REDLANDS BLVD STE U-170
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6109
Mailing Address - Country:US
Mailing Address - Phone:909-633-7413
Mailing Address - Fax:
Practice Address - Street 1:700 E REDLANDS BLVD STE U-170
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-6109
Practice Address - Country:US
Practice Address - Phone:909-633-7413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1043897133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered