Provider Demographics
NPI:1639803927
Name:INDENBAUM-BATES, KEISHA (DNP, FNP-C)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:INDENBAUM-BATES
Suffix:
Gender:F
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 PIN OAK LN
Mailing Address - Street 2:
Mailing Address - City:GLENARDEN
Mailing Address - State:MD
Mailing Address - Zip Code:20706-5512
Mailing Address - Country:US
Mailing Address - Phone:763-568-0549
Mailing Address - Fax:
Practice Address - Street 1:701 SAN MATEO BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1434
Practice Address - Country:US
Practice Address - Phone:505-265-9511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM69599363LF0000X
COC-APN.0004266-C-NP363LF0000X
NV859254363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28651367Medicaid
CO9000207771Medicaid