Provider Demographics
NPI:1831879907
Name:HENDERSON, KIERA A
Entity type:Individual
Prefix:
First Name:KIERA
Middle Name:A
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 N GOLDEN AVE APT 216
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-2730
Mailing Address - Country:US
Mailing Address - Phone:909-269-3506
Mailing Address - Fax:
Practice Address - Street 1:3025 N GOLDEN AVE APT 216
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-2730
Practice Address - Country:US
Practice Address - Phone:909-269-3506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133N00000X, 133V00000X, 133VN1006X, 136A00000X, 174200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174200000XOther Service ProvidersMeals
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered