Provider Demographics
NPI:1336120864
Name:STEVENS, KEISHA CONSUELLA (MD)
Entity Type:Individual
Prefix:DR
First Name:KEISHA
Middle Name:CONSUELLA
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602530
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2530
Mailing Address - Country:US
Mailing Address - Phone:910-642-1776
Mailing Address - Fax:910-642-9305
Practice Address - Street 1:1901 TATE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1109
Practice Address - Country:US
Practice Address - Phone:434-200-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2023-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237387207R00000X, 208M00000X
NC200500118207R00000X
GA054038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2234Medicaid
NC1336120864Medicaid
SCNC2234Medicaid
NCNCJ803BMedicare PIN
NC1336120864Medicaid
I24560Medicare UPIN