Provider Demographics
NPI:1497505390
Name:KEATON, MIESHA N
Entity Type:Individual
Prefix:
First Name:MIESHA
Middle Name:N
Last Name:KEATON
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 1:9008 OLD CLYDESDALE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-3546
Mailing Address - Country:US
Mailing Address - Phone:817-908-2740
Mailing Address - Fax:
Practice Address - Street 1:5260 S HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-1912
Practice Address - Country:US
Practice Address - Phone:817-908-2740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management