Provider Demographics
NPI:1801802749
Name:MARSHALL, KEISHA SIMONE (CNM, WHNP)
Entity type:Individual
Prefix:MS
First Name:KEISHA SIMONE
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:CNM, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 922342
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30010-2342
Mailing Address - Country:US
Mailing Address - Phone:347-770-4588
Mailing Address - Fax:347-507-5777
Practice Address - Street 1:584 E 37TH ST FL 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-5602
Practice Address - Country:US
Practice Address - Phone:347-770-4588
Practice Address - Fax:347-507-5777
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACNM161912367A00000X
NYF-0001355-1367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA8740761928Medicaid