Provider Demographics
NPI:1194492918
Name:WILLIAMS, KEISHA ANN MONIQUE (PNP)
Entity type:Individual
Prefix:MRS
First Name:KEISHA
Middle Name:ANN MONIQUE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:MISS
Other - First Name:KEISHA
Other - Middle Name:ANN MONIQUE
Other - Last Name:QUARRIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2799 ROUTE 112 STE 11&7
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2535
Mailing Address - Country:US
Mailing Address - Phone:631-732-5222
Mailing Address - Fax:631-732-6222
Practice Address - Street 1:2799 ROUTE 112 STE 11AND7
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2535
Practice Address - Country:US
Practice Address - Phone:631-732-5222
Practice Address - Fax:631-732-6222
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-28
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY381475363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics