Healthcare Provider Details

I. General information

NPI: 1114542883
Provider Name (Legal Business Name): KIM EVANS CMT, LE, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 GREGORY LN STE 25
PLEASANT HILL CA
94523-4915
US

IV. Provider business mailing address

PO BOX 4403
WALNUT CREEK CA
94596-0403
US

V. Phone/Fax

Practice location:
  • Phone: 925-639-1629
  • Fax:
Mailing address:
  • Phone: 925-639-1629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number43135
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: