1235488131 NPI number — KEISHIA HENDERSON MACKIE NP

Table of content: KEISHIA HENDERSON MACKIE NP (NPI 1235488131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235488131 NPI number — KEISHIA HENDERSON MACKIE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACKIE
Provider First Name:
KEISHIA
Provider Middle Name:
HENDERSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCOY
Provider Other First Name:
KEISHIA
Provider Other Middle Name:
HENDERSON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235488131
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
441 WALL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRETNA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70056-7723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-371-6597
Provider Business Mailing Address Fax Number:
504-371-6555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
441 WALL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRETNA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70056-7723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-371-6597
Provider Business Practice Location Address Fax Number:
504-371-6555
Provider Enumeration Date:
09/06/2012

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: 363LF0000X , with the licence number:  RN117999 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP07067 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2317679 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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