Provider Demographics
NPI:1467705079
Name:KRESHA, CARMEN (RD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:KRESHA
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 1:12704 FANTASIA DR
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-2941
Mailing Address - Country:US
Mailing Address - Phone:312-952-6012
Mailing Address - Fax:844-246-8462
Practice Address - Street 1:12330 PINECREST RD STE 125
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-1655
Practice Address - Country:US
Practice Address - Phone:312-952-6012
Practice Address - Fax:844-246-8462
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1932743192OtherNPI