Provider Demographics
NPI:1245936657
Name:WALKER, KENITRA NICOLE (CTRS)
Entity type:Individual
Prefix:
First Name:KENITRA
Middle Name:NICOLE
Last Name:WALKER
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4247 GUNAR DR
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-4481
Mailing Address - Country:US
Mailing Address - Phone:601-316-9627
Mailing Address - Fax:
Practice Address - Street 1:310 ABBEY CT APT O5
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4020
Practice Address - Country:US
Practice Address - Phone:601-316-9627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS83885225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist