Provider Demographics
NPI:1235488131
Name:MACKIE, KEISHIA HENDERSON (NP)
Entity Type:Individual
Prefix:
First Name:KEISHIA
Middle Name:HENDERSON
Last Name:MACKIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KEISHIA
Other - Middle Name:HENDERSON
Other - Last Name:MCCOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:441 WALL BLVD
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-7723
Mailing Address - Country:US
Mailing Address - Phone:504-371-6597
Mailing Address - Fax:504-371-6555
Practice Address - Street 1:441 WALL BLVD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-7723
Practice Address - Country:US
Practice Address - Phone:504-371-6597
Practice Address - Fax:504-371-6555
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN117999363LF0000X
LAAP07067363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2317679Medicaid
LA2317679Medicaid