Provider Demographics
NPI:1477361913
Name:CUBBAGE, KESHAHNA
Entity type:Individual
Prefix:
First Name:KESHAHNA
Middle Name:
Last Name:CUBBAGE
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 E 35TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-5001
Mailing Address - Country:US
Mailing Address - Phone:315-520-0938
Mailing Address - Fax:
Practice Address - Street 1:349 E 35TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-5001
Practice Address - Country:US
Practice Address - Phone:315-520-0938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator