Provider Demographics
NPI:1043033194
Name:TWITTY, KANISHA (NDTR)
Entity type:Individual
Prefix:MS
First Name:KANISHA
Middle Name:
Last Name:TWITTY
Suffix:
Gender:F
Credentials:NDTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5618 W RAINWATER DR
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-5704
Mailing Address - Country:US
Mailing Address - Phone:480-404-3501
Mailing Address - Fax:
Practice Address - Street 1:5618 W RAINWATER DR
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-5704
Practice Address - Country:US
Practice Address - Phone:480-404-3501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered