Basic Information
| Provider Information | |||||||||
| NPI: | 1740887264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORBETT | ||||||||
| FirstName: | KEISHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 708 IRVING AVE | ||||||||
| Address2: | |||||||||
| City: | EDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272885618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363445870 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3580 NC 14 | ||||||||
| Address2: | |||||||||
| City: | REIDSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273208746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365225095 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2020 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 323434 | NC | N | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 163W00000X | 324434 | NC | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 323434 | 05 | NC | MEDICAID |