Provider Demographics
NPI:1285215251
Name:FLEMING, KYRISSTON SHANTELL
Entity Type:Individual
Prefix:
First Name:KYRISSTON
Middle Name:SHANTELL
Last Name:FLEMING
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 1:251 CORNWALL ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-2376
Mailing Address - Country:US
Mailing Address - Phone:912-248-7381
Mailing Address - Fax:
Practice Address - Street 1:251 CORNWALL ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-2376
Practice Address - Country:US
Practice Address - Phone:912-248-6082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHCP010521251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health