Provider Demographics
NPI:1669248191
Name:BEVILACQUA, KRISTEN (RDN)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:BEVILACQUA
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9714 W MAXWELL ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67215-1550
Mailing Address - Country:US
Mailing Address - Phone:316-644-7152
Mailing Address - Fax:
Practice Address - Street 1:9415 E HARRY ST STE 407
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-5083
Practice Address - Country:US
Practice Address - Phone:316-252-1154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered