Provider Demographics
NPI:1063022788
Name:CANAKIE-TOLLIVER, KANESHA DAUNDRIA
Entity Type:Individual
Prefix:
First Name:KANESHA
Middle Name:DAUNDRIA
Last Name:CANAKIE-TOLLIVER
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 1:4775 S DURANGO DR STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8157
Mailing Address - Country:US
Mailing Address - Phone:170-280-2358
Mailing Address - Fax:
Practice Address - Street 1:4775 S DURANGO DR STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-8157
Practice Address - Country:US
Practice Address - Phone:170-280-2358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1518369305Medicaid