Provider Demographics
NPI:1942078274
Name:FUSTOS, KRISTEN (MS, RDN, CSP, LD,)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:FUSTOS
Suffix:
Gender:F
Credentials:MS, RDN, CSP, LD,
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:GOOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 130334
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33681-0334
Mailing Address - Country:US
Mailing Address - Phone:813-590-7565
Mailing Address - Fax:813-219-8055
Practice Address - Street 1:PO BOX 130334
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33681-0334
Practice Address - Country:US
Practice Address - Phone:813-590-7565
Practice Address - Fax:813-219-8055
Is Sole Proprietor?:No
Enumeration Date:2023-12-15
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND9388133N00000X
FLALPP-319150174N00000X
FL86118144133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN