Provider Demographics
NPI:1902568157
Name:DAVIS, KENDALL R
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:R
Last Name:DAVIS
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 1:200 LUISITA RD
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1730
Mailing Address - Country:US
Mailing Address - Phone:262-227-6622
Mailing Address - Fax:
Practice Address - Street 1:200 LUISITA RD
Practice Address - Street 2:
Practice Address - City:THIENSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53092-1730
Practice Address - Country:US
Practice Address - Phone:262-227-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered