Provider Demographics
NPI:1679710933
Name:OLIPHANT, KEISHA L (FNP)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:L
Last Name:OLIPHANT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 299
Mailing Address - Street 2:9421 EASTSIDE DRIVE EXT
Mailing Address - City:NEWTON
Mailing Address - State:MS
Mailing Address - Zip Code:39330-0000
Mailing Address - Country:US
Mailing Address - Phone:601-683-2031
Mailing Address - Fax:601-683-0264
Practice Address - Street 1:9421 EASTSIDE DRIVE EXT
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MS
Practice Address - Zip Code:39330-0000
Practice Address - Country:US
Practice Address - Phone:601-683-2031
Practice Address - Fax:601-683-0264
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR861070363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR861070OtherMS BOARD OF NURSING