Healthcare Provider Details

I. General information

NPI: 1003423625
Provider Name (Legal Business Name): KENRESE THERESA CARTER MS,CNS, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KENRESE THERESA CAMPBELL MS, CNS, LDN

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 06/15/2025
Certification Date: 06/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46088 SALTMARSH CT
LEXINGTON PARK MD
20653-2879
US

IV. Provider business mailing address

4344 FAWN LN SE
SMYRNA GA
30082-3951
US

V. Phone/Fax

Practice location:
  • Phone: 404-397-3009
  • Fax:
Mailing address:
  • Phone: 404-397-3009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND14157
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number164012155
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX5094
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: