Provider Demographics
NPI:1356018642
Name:ROUSSEAU, KEYANNA TIARRA
Entity Type:Individual
Prefix:
First Name:KEYANNA
Middle Name:TIARRA
Last Name:ROUSSEAU
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 1:3936 OGBURN AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-3758
Mailing Address - Country:US
Mailing Address - Phone:336-989-6235
Mailing Address - Fax:
Practice Address - Street 1:3936 OGBURN AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-3758
Practice Address - Country:US
Practice Address - Phone:336-989-6235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program