Healthcare Provider Details

I. General information

NPI: 1639912512
Provider Name (Legal Business Name): KESHIA LATRELL WHITTAKER-RIVERS MSN, CRNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 ROSS CLARK CIR
DOTHAN AL
36301-3022
US

IV. Provider business mailing address

11595 WALKER SPRINGS RD
GAINESTOWN AL
36540-3075
US

V. Phone/Fax

Practice location:
  • Phone: 334-791-0820
  • Fax:
Mailing address:
  • Phone: 251-589-8216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1-106025
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: