Provider Demographics
NPI:1184021156
Name:KRUSE, KENDAL WAGNER (RD)
Entity Type:Individual
Prefix:MRS
First Name:KENDAL
Middle Name:WAGNER
Last Name:KRUSE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MS
Other - First Name:KENDAL
Other - Middle Name:WAGNER
Other - Last Name:PIKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 996
Mailing Address - Street 2:
Mailing Address - City:NOME
Mailing Address - State:AK
Mailing Address - Zip Code:99762
Mailing Address - Country:US
Mailing Address - Phone:907-443-3311
Mailing Address - Fax:
Practice Address - Street 1:1000 GREG KRUSCHEK AVENUE
Practice Address - Street 2:
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762
Practice Address - Country:US
Practice Address - Phone:907-443-4589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK347133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered