Provider Demographics
NPI:1063666915
Name:STURDIVANT-EVANS, KEIRSHA T
Entity Type:Individual
Prefix:
First Name:KEIRSHA
Middle Name:T
Last Name:STURDIVANT-EVANS
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 1:997 LANCEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MACEDONIA
Mailing Address - State:OH
Mailing Address - Zip Code:44056-2331
Mailing Address - Country:US
Mailing Address - Phone:216-513-6512
Mailing Address - Fax:
Practice Address - Street 1:997 LANCEWOOD DR
Practice Address - Street 2:
Practice Address - City:MACEDONIA
Practice Address - State:OH
Practice Address - Zip Code:44056-2331
Practice Address - Country:US
Practice Address - Phone:216-513-6512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSA352854172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver