Provider Demographics
NPI:1295094035
Name:STURDEVANT, KERI LOUISE (PA)
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:LOUISE
Last Name:STURDEVANT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16130 PIONCIANA ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418-6508
Mailing Address - Country:US
Mailing Address - Phone:810-357-4159
Mailing Address - Fax:
Practice Address - Street 1:1290 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-4337
Practice Address - Country:US
Practice Address - Phone:869-972-9033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006420363A00000X
TXPA09689363A00000X
CT006076363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1295094035OtherNATIONAL PROVIDER IDENTIFICATION NUMBER