Healthcare Provider Details

I. General information

NPI: 1982451548
Provider Name (Legal Business Name): NAKEISHA KELANI VAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 NW FEDERAL HWY STE 173
STUART FL
34994-1019
US

IV. Provider business mailing address

4011 NW 187TH ST
MIAMI GARDENS FL
33055-2718
US

V. Phone/Fax

Practice location:
  • Phone: 954-579-7973
  • Fax:
Mailing address:
  • Phone: 786-616-9274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: