Provider Demographics
NPI:1003423625
Name:CARTER, KENRESE THERESA (MS,CNS)
Entity Type:Individual
Prefix:
First Name:KENRESE
Middle Name:THERESA
Last Name:CARTER
Suffix:
Gender:F
Credentials:MS,CNS
Other - Prefix:
Other - First Name:KENRESE
Other - Middle Name:THERESA
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CNS
Mailing Address - Street 1:146 BELL RICHARD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459-3513
Mailing Address - Country:US
Mailing Address - Phone:404-397-3009
Mailing Address - Fax:
Practice Address - Street 1:146 BELL RICHARD AVE
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-3513
Practice Address - Country:US
Practice Address - Phone:404-397-3009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist