Provider Demographics
NPI:1407477177
Name:CROCKETT, KENIESHA ANDREA
Entity Type:Individual
Prefix:
First Name:KENIESHA
Middle Name:ANDREA
Last Name:CROCKETT
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 1:2432 MORTON AVE APT C
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-4790
Mailing Address - Country:US
Mailing Address - Phone:702-285-4749
Mailing Address - Fax:
Practice Address - Street 1:2432 MORTON AVE APT C
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-4790
Practice Address - Country:US
Practice Address - Phone:702-285-4749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant