Provider Demographics
NPI:1386225001
Name:PANTRY, KESHA (FNP)
Entity type:Individual
Prefix:
First Name:KESHA
Middle Name:
Last Name:PANTRY
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4941 NW 84TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33351-5555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5308 13TH AVE STE 509
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-5198
Practice Address - Country:US
Practice Address - Phone:929-594-4494
Practice Address - Fax:718-299-6797
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY694261163W00000X
NYF347626363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse