Provider Demographics
NPI:1578063772
Name:BAGGETT, KIASHA SHIREE
Entity Type:Individual
Prefix:MISS
First Name:KIASHA
Middle Name:SHIREE
Last Name:BAGGETT
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 1:3925 N. MARTIN LUTHER KING BLVD.
Mailing Address - Street 2:STE 211
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032
Mailing Address - Country:US
Mailing Address - Phone:702-488-2284
Mailing Address - Fax:
Practice Address - Street 1:3925 N. MARTIN LUTHER KING BLVD.
Practice Address - Street 2:STE 211
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032
Practice Address - Country:US
Practice Address - Phone:702-488-2284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1831602291Medicaid