Provider Demographics
NPI:1508880865
Name:EVANS, KATHLEEN
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 BULLDOG BLVD
Mailing Address - Street 2:STE 202
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3332
Mailing Address - Country:US
Mailing Address - Phone:321-727-2990
Mailing Address - Fax:321-724-0455
Practice Address - Street 1:95 BULLDOG BLVD
Practice Address - Street 2:STE 101
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3332
Practice Address - Country:US
Practice Address - Phone:321-722-9731
Practice Address - Fax:321-308-0496
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND970133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
0991-0187OtherNATIONAL CERT BOARD FOR DIABETES EDUCATORS
FLND970OtherDIETITIAN/NUTRITIONIST
0991-0187OtherNATIONAL CERT BOARD FOR DIABETES EDUCATORS