Provider Demographics
NPI:1467110411
Name:REESE, KEISHAN CHANTELE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:KEISHAN
Middle Name:CHANTELE
Last Name:REESE
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 ASHTON PARK DR SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-4822
Mailing Address - Country:US
Mailing Address - Phone:470-209-0246
Mailing Address - Fax:
Practice Address - Street 1:901 ASHTON PARK DR SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-4822
Practice Address - Country:US
Practice Address - Phone:470-209-0246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN205973291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory