Healthcare Provider Details

I. General information

NPI: 1528526548
Provider Name (Legal Business Name): KISHA MESHUN PEACE AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KISHA MESHUN PEACE MSN, AGNP-C

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 01/14/2026
Certification Date: 01/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5126 HOSPITAL DR NE STE 102
COVINGTON GA
30014-2566
US

IV. Provider business mailing address

508 BETHELVIEW DR
HAMPTON GA
30228-4825
US

V. Phone/Fax

Practice location:
  • Phone: 770-385-4453
  • Fax:
Mailing address:
  • Phone: 850-624-5436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP194819
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNCO-000001
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberNCO-000001
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License NumberRN194819
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberRN194819
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: