Provider Demographics
NPI:1871254128
Name:COLEMAN, KANNESHA
Entity Type:Individual
Prefix:
First Name:KANNESHA
Middle Name:
Last Name:COLEMAN
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 1:4371 CHARLOTTE HWY STE 22
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-8105
Mailing Address - Country:US
Mailing Address - Phone:803-589-7999
Mailing Address - Fax:
Practice Address - Street 1:4371 CHARLOTTE HWY STE 22
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-8105
Practice Address - Country:US
Practice Address - Phone:803-589-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty