Provider Demographics
NPI:1366072068
Name:ROBERTSON, KIRSTEN (RDN, LD)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:
Other - Last Name:GRANBERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 SPRING AVE STE 130
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75210-1350
Practice Address - Country:US
Practice Address - Phone:214-865-3060
Practice Address - Fax:214-865-3070
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85784133VN1201X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT85784OtherTEXAS DEPARTMENT OF LICENSING AND REGULATION