1154946234 NPI number — KEISHA MALIA HEARD

Table of content: KEISHA MALIA HEARD (NPI 1154946234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154946234 NPI number — KEISHA MALIA HEARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEARD
Provider First Name:
KEISHA
Provider Middle Name:
MALIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154946234
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1722A CIRCLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36203-3210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-225-3716
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 E CHOCCOLOCCO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36203-1222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-831-4601
Provider Business Practice Location Address Fax Number:
256-835-3386
Provider Enumeration Date:
06/15/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)