Provider Demographics
NPI:1508495987
Name:TERRELL, KIESHIA
Entity Type:Individual
Prefix:
First Name:KIESHIA
Middle Name:
Last Name:TERRELL
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:PO BOX 26096
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-0096
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:94 W WOODBURY DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-2836
Practice Address - Country:US
Practice Address - Phone:937-684-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN383678163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice