Basic Information
| Provider Information | |||||||||
| NPI: | 1780309542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | KEIRA | ||||||||
| MiddleName: | LASHAWN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEE | ||||||||
| OtherFirstName: | KEIRA | ||||||||
| OtherMiddleName: | LASHAWN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | DEPT LA 22763 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911852763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665234268 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2810 PREMIERE PKWY STE 500 | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300978912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665234268 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2022 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.