Provider Demographics
NPI:1457013351
Name:KEETON, KEVISHA
Entity Type:Individual
Prefix:
First Name:KEVISHA
Middle Name:
Last Name:KEETON
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 1:9600 FOREST LN APT 246
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-5868
Mailing Address - Country:US
Mailing Address - Phone:469-716-1454
Mailing Address - Fax:
Practice Address - Street 1:9600 FOREST LN APT 246
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-5868
Practice Address - Country:US
Practice Address - Phone:469-716-1454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty