Provider Demographics
NPI:1699003137
Name:PUGH, KEISHA D (APRN)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:D
Last Name:PUGH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KEISHA
Other - Middle Name:
Other - Last Name:PITTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:800 PRUDENTIAL DR FL B11
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8202
Mailing Address - Country:US
Mailing Address - Phone:904-388-6518
Mailing Address - Fax:904-384-1005
Practice Address - Street 1:800 PRUDENTIAL DR STE 1100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-388-6518
Practice Address - Fax:904-384-1005
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9194377363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1868Medicare PIN