MEDICARE: MRS. SHARAI LYNN KINGSTON CDR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	136A00000X	Registered Dietetic Technician	86116725	KY

General Provider Information

NPI Number	:	1609412220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHARAI LYNN KINGSTON CDR

Provider Business Mailing Address
First Line	:	2456 LANCASTER RD
Second Line	:
City	:	RICHMOND
State	:	KY
Zip	:	40475-8809
Country	:	US
Telephone Number	:	512-755-3702
Fax Number	:

Provider Business Practice Location Address
First Line	:	2456 LANCASTER RD
Second Line	:
City	:	RICHMOND
State	:	KY
Zip	:	40475-8809
Country	:	US
Telephone Number	:	512-755-3702
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2019
Last Update Date	:	11/19/2019

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