Provider Demographics
NPI:1194076992
Name:NELSON, KEISHA
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:NELSON
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 1:10252 185TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-3106
Mailing Address - Country:US
Mailing Address - Phone:718-454-2523
Mailing Address - Fax:
Practice Address - Street 1:10252 185TH ST
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-3106
Practice Address - Country:US
Practice Address - Phone:718-454-2523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310856164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse