Provider Demographics
NPI:1770450405
Name:EVERETT, KEESHA NICOLE
Entity type:Individual
Prefix:
First Name:KEESHA
Middle Name:NICOLE
Last Name:EVERETT
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 1:2000 PARK ST STE 1011619
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2011
Mailing Address - Country:US
Mailing Address - Phone:803-900-3862
Mailing Address - Fax:
Practice Address - Street 1:2000 PARK ST STE 1011619
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2011
Practice Address - Country:US
Practice Address - Phone:803-900-3862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-18
Last Update Date:2025-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42D2331796291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory