Provider Demographics
NPI:1093313090
Name:AVERA, KRISTEN (RD, LD, CDCES)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:AVERA
Suffix:
Gender:F
Credentials:RD, LD, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 DEERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:181 ARMOUR DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3916
Practice Address - Country:US
Practice Address - Phone:404-981-6533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD005269133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86032146OtherCOMMISSION ON DIETETIC REGISTRATION
GALD005269OtherGEORGIA PROFESSIONAL LICENSING BOARD
22200347OtherCERTIFICATION BOARD FOR DIABETES CARE AND EDUCATION