Provider Demographics
NPI:1992181242
Name:SMITH, KEISHA ALICIA
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:ALICIA
Last Name:SMITH
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 1:1158 E 43RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-4409
Mailing Address - Country:US
Mailing Address - Phone:347-309-8307
Mailing Address - Fax:
Practice Address - Street 1:1158 E 43RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-4409
Practice Address - Country:US
Practice Address - Phone:347-309-8307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-09
Last Update Date:2015-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY578656-1163W00000X
NYF339126-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily