Provider Demographics
NPI:1649832940
Name:DAVIS, KEALANI (RD)
Entity type:Individual
Prefix:
First Name:KEALANI
Middle Name:
Last Name:DAVIS
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 1:4811 EDWARDS RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-2805
Mailing Address - Country:US
Mailing Address - Phone:864-238-3878
Mailing Address - Fax:
Practice Address - Street 1:2309 DEVINE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-2422
Practice Address - Country:US
Practice Address - Phone:864-238-3878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1808133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered