Provider Demographics
NPI:1952182289
Name:PHILLIPS, KEERA KEWONDA MOENAY
Entity Type:Individual
Prefix:MISS
First Name:KEERA
Middle Name:KEWONDA MOENAY
Last Name:PHILLIPS
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 1:3948 EAST RIVER RD
Mailing Address - Street 2:6311
Mailing Address - City:WEST HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14586
Mailing Address - Country:US
Mailing Address - Phone:585-851-2059
Mailing Address - Fax:
Practice Address - Street 1:3948 EAST RIVER RD
Practice Address - Street 2:
Practice Address - City:WEST HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14586
Practice Address - Country:US
Practice Address - Phone:585-851-2059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY348396164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse