Provider Demographics
NPI:1255660205
Name:KIRBY, KEAVERN
Entity Type:Individual
Prefix:
First Name:KEAVERN
Middle Name:
Last Name:KIRBY
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 1:942 BROOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-4002
Mailing Address - Country:US
Mailing Address - Phone:347-419-4919
Mailing Address - Fax:
Practice Address - Street 1:942 BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-4002
Practice Address - Country:US
Practice Address - Phone:347-419-4919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY289395-1164W00000X
NY421290363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty