Provider Demographics
NPI:1518278308
Name:STREETZ, KEISHA
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:STREETZ
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 1:5310 SEQUOIA ROAD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120
Mailing Address - Country:US
Mailing Address - Phone:505-836-7330
Mailing Address - Fax:
Practice Address - Street 1:5310 SEQUOIA ROAD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120
Practice Address - Country:US
Practice Address - Phone:505-836-7330
Practice Address - Fax:505-836-7424
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker