Provider Demographics
NPI:1871843573
Name:ALLEN, KEISHA L (PA-C)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:L
Last Name:ALLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KEISHA
Other - Middle Name:L
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9879 KY ROUTE 122
Mailing Address - Street 2:
Mailing Address - City:MC DOWELL
Mailing Address - State:KY
Mailing Address - Zip Code:41647-6026
Mailing Address - Country:US
Mailing Address - Phone:606-377-3427
Mailing Address - Fax:606-377-3369
Practice Address - Street 1:9879 KENTUCKY ROUTE 122
Practice Address - Street 2:
Practice Address - City:MCDOWELL
Practice Address - State:KY
Practice Address - Zip Code:41647-6042
Practice Address - Country:US
Practice Address - Phone:606-377-3427
Practice Address - Fax:606-377-3369
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1744363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100267780Medicaid
KY7100267780Medicaid