Provider Demographics
NPI:1255168118
Name:KIMBROUGH, KESHANIA S
Entity type:Individual
Prefix:
First Name:KESHANIA
Middle Name:S
Last Name:KIMBROUGH
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 1:3000 W CAPITOL DR APT 304
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2654
Mailing Address - Country:US
Mailing Address - Phone:414-378-2989
Mailing Address - Fax:
Practice Address - Street 1:3000 W CAPITOL DR APT 304
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2654
Practice Address - Country:US
Practice Address - Phone:414-378-2989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician