Basic Information
| Provider Information | |||||||||
| NPI: | 1376193250 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TODD | ||||||||
| FirstName: | KEISHA | ||||||||
| MiddleName: | NICHOLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHYSICIAN ASSISTANT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIDNER | ||||||||
| OtherFirstName: | KEISHA | ||||||||
| OtherMiddleName: | NICHOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHYSICIAN ASSISTANT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1006 | ||||||||
| Address2: | |||||||||
| City: | PINE KNOT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426351006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063101812 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 828 LANE ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405043658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199325700 | ||||||||
| FaxNumber: | 9199336881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2019 | ||||||||
| LastUpdateDate: | 06/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2824 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 4064 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | TC055 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | MT6782482 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 4832 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA2824 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.