Provider Demographics
NPI:1629808886
Name:ETIENNE, KEISHA
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:ETIENNE
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 1:1311 MILSTEAD AVE NE STE 321
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3829
Mailing Address - Country:US
Mailing Address - Phone:678-599-9800
Mailing Address - Fax:
Practice Address - Street 1:1311 MILSTEAD AVE NE STE 321
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3829
Practice Address - Country:US
Practice Address - Phone:678-599-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC9P8A7M3246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy