Provider Demographics
NPI:1255812160
Name:RUSSELL, KEYOTA ANDREA
Entity type:Individual
Prefix:
First Name:KEYOTA
Middle Name:ANDREA
Last Name:RUSSELL
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 1:7001 BUNDY RD APT R10
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70127-2173
Mailing Address - Country:US
Mailing Address - Phone:504-261-2811
Mailing Address - Fax:
Practice Address - Street 1:2408 HOUMA BLVD APT 315
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001
Practice Address - Country:US
Practice Address - Phone:504-261-2811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0083422717343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)