Provider Demographics
NPI:1588302327
Name:FAWCETT, KINDANN MCMAHAN STONE (PHD, RD, LD)
Entity type:Individual
Prefix:DR
First Name:KINDANN
Middle Name:MCMAHAN STONE
Last Name:FAWCETT
Suffix:
Gender:F
Credentials:PHD, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-3034
Mailing Address - Country:US
Mailing Address - Phone:501-605-0310
Mailing Address - Fax:501-605-0325
Practice Address - Street 1:305 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-3034
Practice Address - Country:US
Practice Address - Phone:501-605-0310
Practice Address - Fax:501-605-0325
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011976-01133N00000X
OK2919133V00000X
TXDT87888133V00000X
AR2244133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR6K3543Medicaid