Provider Demographics
NPI:1467107318
Name:EASON, KEIONTAE
Entity Type:Individual
Prefix:MRS
First Name:KEIONTAE
Middle Name:
Last Name:EASON
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 1:940 GA HIGHWAY 96
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-2584
Mailing Address - Country:US
Mailing Address - Phone:478-988-7100
Mailing Address - Fax:478-988-6847
Practice Address - Street 1:940 GA HIGHWAY 96 STE C
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-2585
Practice Address - Country:US
Practice Address - Phone:478-988-7100
Practice Address - Fax:478-988-6847
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN295202163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Multi-Specialty