Provider Demographics
NPI:1417720806
Name:LAND, KEENYA S
Entity Type:Individual
Prefix:
First Name:KEENYA
Middle Name:S
Last Name:LAND
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 1:4316 LINDSEY WAY NE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1614
Mailing Address - Country:US
Mailing Address - Phone:770-676-1985
Mailing Address - Fax:
Practice Address - Street 1:4316 LINDSEY WAY NE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-1614
Practice Address - Country:US
Practice Address - Phone:770-676-1985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No171400000XOther Service ProvidersHealth & Wellness Coach