Basic Information
| Provider Information | |||||||||
| NPI: | 1669420709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EWING | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | N.M. | ||||||||
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| Credential: | RDLD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 SIXTH AVE N | ||||||||
| Address2: | CENTRACARE CLINIC | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202525131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 SIXTH AVE N | ||||||||
| Address2: | CENTRACARE CLINIC | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202525131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 07/19/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2390 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | HEALTHPARTNERS | 01 | HP48003 | OTHER | MEDICA | 01 | 6300338 | OTHER | 092ROEW | 01 | MN | BCBSM | OTHER |