Provider Demographics
NPI:1346669223
Name:CHAMBLISS, KESHAN LAFAYE
Entity Type:Individual
Prefix:DR
First Name:KESHAN
Middle Name:LAFAYE
Last Name:CHAMBLISS
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 1:5846 FELIX DR N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32219-3809
Mailing Address - Country:US
Mailing Address - Phone:904-334-3369
Mailing Address - Fax:904-924-9907
Practice Address - Street 1:5846 FELIX DR N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32219-3809
Practice Address - Country:US
Practice Address - Phone:904-334-3369
Practice Address - Fax:904-924-9907
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-08
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689237079Medicaid
FL689237096Medicaid