Provider Demographics
NPI:1134620842
Name:GRIFFIN, KEIANA
Entity type:Individual
Prefix:
First Name:KEIANA
Middle Name:
Last Name:GRIFFIN
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 1:349 BARTLEY RD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-3015
Mailing Address - Country:US
Mailing Address - Phone:386-843-0597
Mailing Address - Fax:
Practice Address - Street 1:702 N 19TH ST STE 10
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3063
Practice Address - Country:US
Practice Address - Phone:386-843-0597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid