Basic Information
| Provider Information | |||||||||
| NPI: | 1417185521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAWSON | ||||||||
| FirstName: | KEISHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 1ST ST N | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322506945 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15320 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LYTLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780523550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8307095777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 06/26/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | 2070862 | TX | Y | Other Service Providers | Community Health Worker | 172V00000X | PTA 2186 | AR | N | Other Service Providers | Community Health Worker |
No ID Information.