Provider Demographics
NPI:1912521626
Name:ALLEN, KENNETH JEFFERSON III (RD, LDN)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JEFFERSON
Last Name:ALLEN
Suffix:III
Gender:M
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 BARNETT AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2240
Mailing Address - Country:US
Mailing Address - Phone:910-622-3096
Mailing Address - Fax:
Practice Address - Street 1:2106 BARNETT AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2240
Practice Address - Country:US
Practice Address - Phone:910-622-3096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC004802133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered