Provider Demographics
NPI:1376193250
Name:TODD, KEISHA NICHOLE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:KEISHA
Middle Name:NICHOLE
Last Name:TODD
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:KEISHA
Other - Middle Name:NICHOLE
Other - Last Name:RIDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:PO BOX 1006
Mailing Address - Street 2:
Mailing Address - City:PINE KNOT
Mailing Address - State:KY
Mailing Address - Zip Code:42635-1006
Mailing Address - Country:US
Mailing Address - Phone:606-310-1812
Mailing Address - Fax:
Practice Address - Street 1:828 LANE ALLEN RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3658
Practice Address - Country:US
Practice Address - Phone:919-932-5700
Practice Address - Fax:919-933-6881
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2824363A00000X, 363AM0700X
TN4064363AM0700X
363AM0700X
KYTC055363AM0700X
KYMT6782482363AM0700X
TN4832363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant