MEDICARE: KRISTEN AVERA RD, LD, CDCES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	LD005269	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86032146	OTHER		COMMISSION ON DIETETIC REGISTRATION
2	LD005269	OTHER	GA	GEORGIA PROFESSIONAL LICENSING BOARD
3	22200347	OTHER		CERTIFICATION BOARD FOR DIABETES CARE AND EDUCATION

General Provider Information

NPI Number	:	1093313090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN AVERA RD, LD, CDCES

Provider Business Mailing Address
First Line	:	1524 DEERWOOD DR
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-4516
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1380 W MARIETTA ST NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-4974
Country	:	US
Telephone Number	:	404-981-6533
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2020
Last Update Date	:	05/22/2026

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