Provider Demographics
NPI:1619164118
Name:EVANS, KIMBERLY A (MS RD)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:A
Last Name:EVANS
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:220 NARRAGANSETT AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-5608
Mailing Address - Country:US
Mailing Address - Phone:802-391-9076
Mailing Address - Fax:802-503-0556
Practice Address - Street 1:117 KENDRICK ST STE 300
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-2722
Practice Address - Country:US
Practice Address - Phone:802-391-9076
Practice Address - Fax:802-503-0556
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1017597Medicaid