Provider Demographics
NPI:1912066812
Name:HEATH, KENISHA RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENISHA
Middle Name:RENEE
Last Name:HEATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15301 WARREN SHINGLE RD
Mailing Address - Street 2:
Mailing Address - City:BEALE AFB
Mailing Address - State:CA
Mailing Address - Zip Code:95903-1907
Mailing Address - Country:US
Mailing Address - Phone:530-634-4662
Mailing Address - Fax:
Practice Address - Street 1:9MDG
Practice Address - Street 2:15301 WARREN SHINGLE ROAD
Practice Address - City:BEALE
Practice Address - State:CA
Practice Address - Zip Code:95648
Practice Address - Country:UM
Practice Address - Phone:530-634-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060445A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine