Provider Demographics
NPI:1982145587
Name:ANDERSON, KEA'ASHA (LPN)
Entity Type:Individual
Prefix:
First Name:KEA'ASHA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 NE 22ND TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32641-4744
Mailing Address - Country:US
Mailing Address - Phone:910-689-6391
Mailing Address - Fax:
Practice Address - Street 1:900 NE 22ND TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32641-4744
Practice Address - Country:US
Practice Address - Phone:910-689-6391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN 5224029164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse