Provider Demographics
NPI:1518504307
Name:KEYAKA, ERNEST
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:KEYAKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15305 BEAUFORT PL
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-4203
Mailing Address - Country:US
Mailing Address - Phone:513-295-9807
Mailing Address - Fax:
Practice Address - Street 1:5718 HARFORD RD STE 103
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-2239
Practice Address - Country:US
Practice Address - Phone:513-295-9807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2019051520363L00000X
MDR208967363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner