Provider Demographics
NPI:1407540602
Name:WALLACE-KEESHEN, SARA ELIZABETH (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:SARA
Middle Name:ELIZABETH
Last Name:WALLACE-KEESHEN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 AGATE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-2302
Mailing Address - Country:US
Mailing Address - Phone:864-275-4820
Mailing Address - Fax:
Practice Address - Street 1:2144 CECIL B MOORE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-4014
Practice Address - Country:US
Practice Address - Phone:215-320-6187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP027631363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care