Provider Demographics
NPI:1174375984
Name:ETZLER, KRISTEN (MS, RD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:ETZLER
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:OH
Mailing Address - Zip Code:43105-1248
Mailing Address - Country:US
Mailing Address - Phone:419-605-3170
Mailing Address - Fax:
Practice Address - Street 1:900 E DUBLIN GRANVILLE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-2452
Practice Address - Country:US
Practice Address - Phone:614-953-5219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.10465133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered