Basic Information
| Provider Information | |||||||||
| NPI: | 1932498060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANUL | ||||||||
| FirstName: | KRISTI | ||||||||
| MiddleName: | |||||||||
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| Credential: | REGISTERED DIETITIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7905 CALUMET AVE | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198365800 | ||||||||
| FaxNumber: | 2198367226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2011 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164005403 | IL | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 37000452A | IN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | F400316855 | 01 | FRANCISCAN PHYSICIAN NETWORK MEDICARE INDIVIDUAL IL PTAN | OTHER |