Provider Demographics
NPI:1023201381
Name:DOUGLAS, KENYATTA
Entity Type:Individual
Prefix:
First Name:KENYATTA
Middle Name:
Last Name:DOUGLAS
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 1:8060 KNUE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250
Mailing Address - Country:US
Mailing Address - Phone:317-842-7435
Mailing Address - Fax:317-842-7674
Practice Address - Street 1:8060 KNUE RD
Practice Address - Street 2:SUITE 110 GENERAL HEALTHCARE RESOURCES IN
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250
Practice Address - Country:US
Practice Address - Phone:317-842-7435
Practice Address - Fax:317-842-7674
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN48010503137376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide