Basic Information
| Provider Information | |||||||||
| NPI: | 1033371786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTRAND | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD,LD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GIERSCH | ||||||||
| OtherFirstName: | CRYSTAL | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2090 S OHIO ST | ||||||||
| Address2: | |||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 674016702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858258221 | ||||||||
| FaxNumber: | 7854527530 | ||||||||
| Practice Location | |||||||||
| Address1: | 2090 S OHIO ST | ||||||||
| Address2: | |||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 674016702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858258221 | ||||||||
| FaxNumber: | 7854527530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2008 | ||||||||
| LastUpdateDate: | 04/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1006X | 1262 | KS | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic | 133V00000X | 1262 | KS | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 201069820A | 05 | KS | MEDICAID |