Basic Information
| Provider Information | |||||||||
| NPI: | 1871843573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | KEISHA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | KEISHA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9879 KY ROUTE 122 | ||||||||
| Address2: | |||||||||
| City: | MC DOWELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 416476026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063773427 | ||||||||
| FaxNumber: | 6063773369 | ||||||||
| Practice Location | |||||||||
| Address1: | 9879 KENTUCKY ROUTE 122 | ||||||||
| Address2: | |||||||||
| City: | MCDOWELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 416476042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063773427 | ||||||||
| FaxNumber: | 6063773369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2012 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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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 | 363A00000X | PA1744 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100267780 | 05 | KY | MEDICAID |