Provider Demographics
NPI:1093266496
Name:JUSTICE, KEISHIA (CMF)
Entity type:Individual
Prefix:
First Name:KEISHIA
Middle Name:
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:CMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 TIFFANY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-1802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:661 TIFFANY BLVD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-1802
Practice Address - Country:US
Practice Address - Phone:252-904-2581
Practice Address - Fax:252-557-3557
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC54057224900000X
NC1517237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00441264Medicaid