Provider Demographics
NPI:1275119232
Name:PARKE SMITH, KEISHA SEREEN
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:SEREEN
Last Name:PARKE SMITH
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 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-6423
Mailing Address - Fax:410-500-4266
Practice Address - Street 1:1232 RACE ROAD
Practice Address - Street 2:STE 403
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-2123
Practice Address - Country:US
Practice Address - Phone:443-868-7101
Practice Address - Fax:443-732-0054
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR166453363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily