Provider Demographics
NPI:1689117616
Name:THOMPSON, KEISHA
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:THOMPSON
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 1:1245 EASTERN PKWY
Mailing Address - Street 2:APT 9B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-4115
Mailing Address - Country:US
Mailing Address - Phone:347-423-1039
Mailing Address - Fax:
Practice Address - Street 1:1245 EASTERN PKWY
Practice Address - Street 2:APT 9B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-4115
Practice Address - Country:US
Practice Address - Phone:347-423-1039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY326975164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse