Provider Demographics
NPI:1760963847
Name:ANDERSON, KEANNA ASHLEY (LVN)
Entity Type:Individual
Prefix:
First Name:KEANNA
Middle Name:ASHLEY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:KEANNNA
Other - Middle Name:ASHLEY
Other - Last Name:BUTLER ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LVN
Mailing Address - Street 1:4849 FRANKFORD RD APT 4310
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-5315
Mailing Address - Country:US
Mailing Address - Phone:323-406-0418
Mailing Address - Fax:
Practice Address - Street 1:4849 FRANKFORD RD APT 4310
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-5315
Practice Address - Country:US
Practice Address - Phone:323-406-0418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX342674164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse