Provider Demographics
NPI:1962033563
Name:MCCLOUD, KEESHA
Entity Type:Individual
Prefix:
First Name:KEESHA
Middle Name:
Last Name:MCCLOUD
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 1:7674 MOUNTAIN CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-3783
Mailing Address - Country:US
Mailing Address - Phone:678-368-2745
Mailing Address - Fax:
Practice Address - Street 1:7674 MOUNTAIN CREEK WAY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-3783
Practice Address - Country:US
Practice Address - Phone:678-368-2745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-01
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2020-12638372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4436Medicaid