Provider Demographics
NPI:1619400074
Name:HOUSE, KEISHA NICOLE
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:NICOLE
Last Name:HOUSE
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 1:3240 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-2405
Mailing Address - Country:US
Mailing Address - Phone:312-413-7425
Mailing Address - Fax:312-413-2588
Practice Address - Street 1:3240 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-2405
Practice Address - Country:US
Practice Address - Phone:312-413-7425
Practice Address - Fax:312-413-2588
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277000995363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily