Provider Demographics
NPI:1700327236
Name:ABBOTT, KESHIA
Entity Type:Individual
Prefix:
First Name:KESHIA
Middle Name:
Last Name:ABBOTT
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 1:127 N OAK AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 W 4TH ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2447
Practice Address - Country:US
Practice Address - Phone:931-783-2143
Practice Address - Fax:931-783-2152
Is Sole Proprietor?:No
Enumeration Date:2017-03-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22439363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ027421Medicaid
KY7100470230Medicaid
TN6102285OtherBCBS