Provider Demographics
NPI:1114542883
Name:EVANS, KIM (CMT, LE, MA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:CMT, LE, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4403
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-0403
Mailing Address - Country:US
Mailing Address - Phone:925-639-1629
Mailing Address - Fax:
Practice Address - Street 1:101 GREGORY LN STE 25
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4915
Practice Address - Country:US
Practice Address - Phone:925-639-1629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43135133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty