Provider Demographics
NPI:1184830358
Name:FALLIN-BENNETT, KEISA (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:KEISA
Middle Name:
Last Name:FALLIN-BENNETT
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2195 HARRODSBURG RD STE 125
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-0001
Mailing Address - Country:US
Mailing Address - Phone:859-323-6711
Mailing Address - Fax:
Practice Address - Street 1:2195 HARRODSBURG RD STE 125
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3504
Practice Address - Country:US
Practice Address - Phone:859-323-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine