Provider Demographics
NPI:1346953841
Name:SMITH, KESHA
Entity Type:Individual
Prefix:
First Name:KESHA
Middle Name:
Last Name: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:PO BOX 1452
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-1000
Mailing Address - Country:US
Mailing Address - Phone:770-881-3557
Mailing Address - Fax:
Practice Address - Street 1:2310 PARKLAKE DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2913
Practice Address - Country:US
Practice Address - Phone:770-294-0437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health