Provider Demographics
NPI:1154142115
Name:HOOPER, KEYASHA AALIYAH
Entity type:Individual
Prefix:
First Name:KEYASHA
Middle Name:AALIYAH
Last Name:HOOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 MCBRIDE ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-4207
Mailing Address - Country:US
Mailing Address - Phone:864-363-7080
Mailing Address - Fax:
Practice Address - Street 1:222 S MAIN ST STE 500
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2275
Practice Address - Country:US
Practice Address - Phone:505-382-2776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61610310363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner