Provider Demographics
NPI:1750828588
Name:WALLACE, KEESHA MICHELLE (RN,BSN)
Entity Type:Individual
Prefix:
First Name:KEESHA
Middle Name:MICHELLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN,BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:982 PRINCESS DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1147
Mailing Address - Country:US
Mailing Address - Phone:734-620-2584
Mailing Address - Fax:
Practice Address - Street 1:982 PRINCESS DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-1147
Practice Address - Country:US
Practice Address - Phone:734-620-2584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704311979163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse