Provider Demographics
NPI:1477023448
Name:SUSSO, KEYLESHA (RCS, RVS)
Entity Type:Individual
Prefix:
First Name:KEYLESHA
Middle Name:
Last Name:SUSSO
Suffix:
Gender:F
Credentials:RCS, RVS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 CUSTER RD STE 270-464
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-4422
Mailing Address - Country:US
Mailing Address - Phone:469-968-2684
Mailing Address - Fax:
Practice Address - Street 1:1705 COIT RD APT 1017
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-6146
Practice Address - Country:US
Practice Address - Phone:469-968-2684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00080850246XS1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography