Provider Demographics
NPI:1003368705
Name:FLETCHER, KAMEELAH
Entity Type:Individual
Prefix:
First Name:KAMEELAH
Middle Name:
Last Name:FLETCHER
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:PO BOX 4394
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68504-0394
Mailing Address - Country:US
Mailing Address - Phone:402-802-2441
Mailing Address - Fax:
Practice Address - Street 1:4826 MADISON AVE #5
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NEBRASKA
Practice Address - Zip Code:68504
Practice Address - Country:UM
Practice Address - Phone:402-802-2441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE43564329320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities