Provider Demographics
NPI:1780262014
Name:HARRIS, KIESHA
Entity type:Individual
Prefix:
First Name:KIESHA
Middle Name:
Last Name:HARRIS
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 1:5545 MURRAY AVE STE 207 PMB 2852
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3898
Mailing Address - Country:US
Mailing Address - Phone:502-259-0196
Mailing Address - Fax:502-259-0196
Practice Address - Street 1:1150 DOVECREST RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-7621
Practice Address - Country:US
Practice Address - Phone:502-259-0196
Practice Address - Fax:502-259-0196
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29259363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily