Provider Demographics
NPI:1295274199
Name:BEAVERS, KIMBERLY A (MS, RDN, LD, CDE)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:BEAVERS
Suffix:
Gender:F
Credentials:MS, RDN, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 RIVER OAK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3282
Mailing Address - Country:US
Mailing Address - Phone:706-922-8283
Mailing Address - Fax:706-854-0317
Practice Address - Street 1:3154 PERIMETER PKWY
Practice Address - Street 2:SUITE 2
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4804
Practice Address - Country:US
Practice Address - Phone:706-922-8283
Practice Address - Fax:706-854-0317
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1299133V00000X
GALD001544133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered