Provider Demographics
NPI:1023506862
Name:BONYFIELD, KEISHA ROICHELLE (APRN)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:ROICHELLE
Last Name:BONYFIELD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KINGS HIGHWAY
Mailing Address - Street 2:ATTN: LEISA OGLESBY (RM. 1-201)
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-4881
Mailing Address - Fax:318-675-5069
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103
Practice Address - Country:US
Practice Address - Phone:318-795-2638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09681207T00000X
LAAPO9681363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery