Provider Demographics
NPI:1891164596
Name:KE, THERESA (LPN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 E FAIRMOUNT AVE #208
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016
Mailing Address - Country:US
Mailing Address - Phone:602-663-8080
Mailing Address - Fax:
Practice Address - Street 1:2924 E FAIRMOUNT AVE APT 208
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6943
Practice Address - Country:US
Practice Address - Phone:602-663-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP048207164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse