Provider Demographics
NPI:1740887264
Name:CORBETT, KEISHA
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:CORBETT
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 1:708 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5618
Mailing Address - Country:US
Mailing Address - Phone:336-344-5870
Mailing Address - Fax:
Practice Address - Street 1:3580 NC 14
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-8746
Practice Address - Country:US
Practice Address - Phone:336-522-5095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC323434163WA0400X
NC324434163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC323434Medicaid