Provider Demographics
NPI:1720557184
Name:CHERON, KESHA EDEN
Entity Type:Individual
Prefix:
First Name:KESHA
Middle Name:EDEN
Last Name:CHERON
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 1:110 BRADFORD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-6311
Mailing Address - Country:US
Mailing Address - Phone:973-393-0551
Mailing Address - Fax:
Practice Address - Street 1:176 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1121
Practice Address - Country:US
Practice Address - Phone:201-795-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403860363LP0808X
NJ26NJJ00851700363LP0808X
NY308957363LA2200X
NJ26NJ00851700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health