Provider Demographics
NPI:1467129205
Name:KESHTA, NOURA
Entity Type:Individual
Prefix:
First Name:NOURA
Middle Name:
Last Name:KESHTA
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 1:4021 ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1949
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:944 S YORK ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5157
Practice Address - Country:US
Practice Address - Phone:630-834-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-28
Last Update Date:2021-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.3040143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051304014OtherRPH LICENSE