Provider Demographics
NPI:1609412220
Name:KINGSTON, SHARAI LYNN (CDR)
Entity type:Individual
Prefix:MRS
First Name:SHARAI
Middle Name:LYNN
Last Name:KINGSTON
Suffix:
Gender:F
Credentials:CDR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2456 LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8809
Mailing Address - Country:US
Mailing Address - Phone:512-755-3702
Mailing Address - Fax:
Practice Address - Street 1:2456 LANCASTER RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-8809
Practice Address - Country:US
Practice Address - Phone:512-755-3702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY86116725136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered