Provider Demographics
NPI:1003423625
Name:CARTER, KENRESE THERESA (MS,CNS)
Entity type:Individual
Prefix:
First Name:KENRESE
Middle Name:THERESA
Last Name:CARTER
Suffix:
Gender:
Credentials:MS,CNS
Other - Prefix:
Other - First Name:KENRESE
Other - Middle Name:THERESA
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CNS
Mailing Address - Street 1:4344 FAWN LN SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-3951
Mailing Address - Country:US
Mailing Address - Phone:404-397-3009
Mailing Address - Fax:
Practice Address - Street 1:46088 SALTMARSH CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653-2879
Practice Address - Country:US
Practice Address - Phone:404-397-3009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2025-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX5094133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist