Healthcare Provider Details

I. General information

NPI: 1982257564
Provider Name (Legal Business Name): KEISHA LANETTE MUHAMMAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KEISHA LANETTE FLANAGAN

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 E HOSPITALITY LN STE 400
SAN BERNARDINO CA
92408-3545
US

IV. Provider business mailing address

506 E HOSPITALITY LANE SUITE 400
SAN BERNARDINO CA
92408
US

V. Phone/Fax

Practice location:
  • Phone: 909-891-1599
  • Fax: 877-306-6790
Mailing address:
  • Phone: 909-891-1599
  • Fax: 877-306-6790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-50738
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: