Provider Demographics
NPI:1083353056
Name:HENLEY, KENTAURIA (RD)
Entity Type:Individual
Prefix:
First Name:KENTAURIA
Middle Name:
Last Name:HENLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 JOHNSONS LN
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:MS
Mailing Address - Zip Code:39083-8601
Mailing Address - Country:US
Mailing Address - Phone:601-265-1014
Mailing Address - Fax:
Practice Address - Street 1:1020 JOHNSONS LN
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-8601
Practice Address - Country:US
Practice Address - Phone:601-265-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD2202133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty