Provider Demographics
NPI:1376031740
Name:DOHERTY, KIESHIA M
Entity Type:Individual
Prefix:
First Name:KIESHIA
Middle Name:M
Last Name:DOHERTY
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 45698
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70895-4698
Mailing Address - Country:US
Mailing Address - Phone:225-924-9164
Mailing Address - Fax:
Practice Address - Street 1:7569 E INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-7518
Practice Address - Country:US
Practice Address - Phone:225-924-9164
Practice Address - Fax:225-924-5479
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty