Provider Demographics
NPI:1164974986
Name:WITHERSPOON, KEISHA
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:WITHERSPOON
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 1:610 UPTOWN BLVD STE 2000
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-3528
Mailing Address - Country:US
Mailing Address - Phone:972-716-2969
Mailing Address - Fax:214-594-8747
Practice Address - Street 1:610 UPTOWN BLVD STE 2000
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-3528
Practice Address - Country:US
Practice Address - Phone:972-716-2969
Practice Address - Fax:214-594-8747
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132272363LP0808X
OR201902386NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX743838OtherLICENSE
TXAP132272OtherLICENSE